Vector Volume 12 Issue 2 - 2018
V O L U M E 1 2 I S S U E 2 F O U N D E D 2 0 0 6 FEATURE: Manifesto à la mode (p.2) REVIEW: Pornography - the psychological and REVIEW: Pornography - the neurobiological effects of a psychological and neurobiological $97 billion industry (p.14) effects of a $97 billion industry (p.15) FEATURE: Manifesto à la mode (p.2) ORIGINAL RESEARCH: Comprehensive healthcare interventions ORIGINAL RESEARCH: Comprehensive in Ethiopian STI clinics healthcare interventions in Ethiopian 1 STI (p.36) clinics (p.33)
- Page 2 and 3: Advisory Board The Advisory Board c
- Page 4 and 5: Foreword Aidan Tan Once, standing a
- Page 6 and 7: and deaths that it can cause when n
- Page 8 and 9: 8. Business and Human Rights Resour
- Page 10 and 11: it is responsive to their health ne
- Page 12 and 13: developing nation, with considerabl
- Page 14 and 15: their function. For instance, the n
- Page 16 and 17: Acknowledgements Commentary and rev
- Page 18 and 19: The cultivation of sexual abuse, mi
- Page 20 and 21: References 1. Owens E, Behun R, Man
- Page 22 and 23: individuals, both within healthcare
- Page 24 and 25: legal name including financial capa
- Page 26 and 27: in this review and are reflective o
- Page 28 and 29: Asia OR Afghanistan OR India OR Sri
- Page 30 and 31: held beliefs within their respectiv
- Page 32 and 33: In Lao PDR (LPDR), the prevalence o
- Page 34 and 35: [31, 52, 55, 65, 70] Traditionally,
- Page 36 and 37: eview suggested that structural fac
- Page 38 and 39: Bank. Available from: http://docume
- Page 40 and 41: HIV during unprotected sex.[5-8] Th
- Page 42 and 43: the test had been performed within
- Page 44 and 45: in data retrieval and manuscript co
- Page 46 and 47: An open letter to our social media
- Page 48 and 49: in the aftermath of the 2018 Marjor
- Page 50 and 51: Rulebook”. This rulebook will be
V O L U M E 1 2 I S S U E 2 F O U N D E D 2 0 0 6<br />
FEATURE: Manifesto à la<br />
mode (p.2)<br />
REVIEW: Pornography - the<br />
psychological and<br />
REVIEW: Pornography - the<br />
neurobiological effects of a<br />
psychological and neurobiological<br />
$97 billion industry (p.14)<br />
effects of a $97 billion industry (p.15)<br />
FEATURE: Manifesto<br />
à la mode (p.2)<br />
ORIGINAL RESEARCH:<br />
Comprehensive<br />
healthcare interventions<br />
ORIGINAL RESEARCH: Comprehensive<br />
in Ethiopian STI clinics<br />
healthcare interventions in Ethiopian 1 STI<br />
(p.36)<br />
clinics (p.33)
Advisory Board<br />
The Advisory Board consists of academic mentors who provide guidance for the present and future<br />
direction of <strong>Vector</strong> Journal.<br />
Dr Claudia Turner<br />
Consultant paediatrician and clinician scientist with the University of Oxford and chief executive officer<br />
of Angkor Hospital for Children.<br />
Professor David Hilmers<br />
Professor in the Departments of Internal Medicine and Pediatrics, the Center for Global Initiatives, and<br />
the Center for Space Medicine at the Baylor College of Medicine.<br />
Associate Professor Nicodemus Tedla<br />
Associate Professor in the School of Medical Sciences at the University of New South Wales.<br />
Dr Nick Walsh<br />
Medical doctor and regional advisor for viral hepatitis at the Pan American Health Organization / World<br />
Health Organization Regional Office for the Americas.<br />
Thank you to the peer-reviewers of <strong>Vector</strong> Journal <strong>12</strong> <strong>Issue</strong> 2:<br />
Professor Michael Toole AM<br />
Dr Rahul Gupta<br />
Dr Paul Simpson<br />
Associate Professor Nicodemus Tedla<br />
Dr Stuart Wark<br />
Dr Bridget Haire<br />
Dr Renju Cherian<br />
<strong>Vector</strong> Journal <strong>2018</strong> Committee<br />
Editor-in-chief<br />
Aidan Tan aidan.tan@amsa.org.au<br />
Senior Editors<br />
Nicholas Mattock<br />
Associate Editors<br />
Sophia Moshegov<br />
Matthew Martin<br />
Simran Dahiya<br />
Tasmyn Soller<br />
Koshy Mathew<br />
Aimy Yan<br />
Kyrollos Hanna<br />
Tessa Tan<br />
Nina Li<br />
Publication Director<br />
Nina Li<br />
Promotion Director<br />
Tessa Tan<br />
Design and layout<br />
© <strong>2018</strong>, <strong>Vector</strong> Journal<br />
vector.amsa.org.au<br />
Content<br />
© <strong>2018</strong>, The Authors<br />
Cover design image by Ryoji Iwata, accessed from https://unsplash.com/photos/_dVxl4eE1rk. Backpage design image by Cristian Newman, accessed<br />
from https://unsplash.com/photos/wGKCaRbElmk.<br />
<strong>Vector</strong> Journal is a peer-reviewed and student-run global health journal.<br />
Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not<br />
necessarily reflect the views of the <strong>Vector</strong> Journal.<br />
i
CONTENTS<br />
Foreword 1<br />
Aidan Tan<br />
FEATURES<br />
Manifesto à la mode 2<br />
Aneka R Larsen<br />
Exploring the ethics and legality of conducting clinical trials in developing nations 6<br />
Rosemary B Kirk<br />
The changing landscape of artificial neural stimulation and its introduction to the developing<br />
world 10<br />
Stephanie Kirkby<br />
REVIEWS<br />
Pornography: the psychological and neurobiological effects of a $97 billion industry 14<br />
Bridie H Peters<br />
Improving interactions between transgender and other gender-diverse persons and the healthcare<br />
system 18<br />
Meredith Grey & Imogen Janus<br />
The public perception of major depressive disorder in South Asia: a literature review 24<br />
Marisse Sonido<br />
Guidelines for low birth weight: a literature review comparing national guidelines in Lao PDR with<br />
WHO guidelines 28<br />
Line M Pederson<br />
ORIGINAL RESEARCH<br />
The experience of Mekelle University in provision of comprehensive healthcare interventions at<br />
STI clinics for FSWs in Ethiopia 36<br />
Tesfay Gebregzabher Gebrehiwot<br />
EDITORIAL<br />
An open letter to our social media overlords 43<br />
Nina Li<br />
CONFERENCE REPORT<br />
United Nations Climate Conference 46<br />
Georgia Behrens & Katherine Middleton<br />
BOOK REVIEW<br />
There is No Me Without You 50<br />
Juliana Wu<br />
ii
Foreword<br />
Aidan Tan<br />
Once, standing ankle deep in the wet sand, I thought that I heard<br />
the Pacific Ocean in a conch shell. The conch shell, I theorised, was<br />
an Earth-bound black hole in thermal equilibrium, absorbing the<br />
temper of the tide and emitting a lost Vivaldi, ‘The Four Seasons of<br />
the Submerged’. Turns out, there are no oceans in conch shells, only<br />
the attenuated frequencies of ambient noise in a calcium carbonate<br />
cavity. I prefer the ocean.<br />
Now, with an active imagination and origami instructions,<br />
you can turn this issue of <strong>Vector</strong> Journal into your own conch<br />
shell. If you listen carefully, you might just hear a call for ethical<br />
fashion by medical students, debate on clinical trials in developing<br />
nations, dialogue on developments in artificial neural stimulation,<br />
discussion on the effects of internet pornography, report on<br />
transgender and other gender-diverse persons, critique of South<br />
Asian perceptions of depression, summary of low birth weight<br />
in Laos, study of sexually transmitted infections in Ethiopia,<br />
commentary on social media causing psychological distress, recount<br />
of the United Nations Climate Conference, or review of a book on<br />
AIDS in Africa. Whatever you hear, I hope it strikes a chord with you.<br />
1
Manifesto à la mode<br />
Feature article<br />
Aneka R Larsen<br />
Aneka R Larsen is a final year medical student at the University of Sydney<br />
who spends far too much time thinking about clothes, and not enough<br />
time studying.<br />
Despite what your mother may have told you,<br />
it’s not just what’s on the inside that counts. As<br />
medical students, our external image matters<br />
greatly. We dress to impress, to show patients<br />
that we are capable and trustworthy. But how<br />
would our patients feel if they knew who made<br />
our clothes? Sustainable fashion is by no means<br />
a new idea, and most people I know support<br />
the idea, yet many of us still wear brands that<br />
are known to engage in unethical practices.<br />
Although we as medical students generally wish<br />
to improve others’ quality of life, too often we<br />
put ethics on the backburner as we convince<br />
ourselves that we are too busy, too tired, too<br />
whatever-it-happens-to-be that day, to think of<br />
the consequences of our actions. If we were truly<br />
compassionate, it would seem incongruent that<br />
we would not also express this in choosing which<br />
brands to support.<br />
After becoming increasingly concerned, I<br />
discussed the issue with a friend who told me<br />
that given the opportunity, most people will<br />
choose to do good. That is, most people don’t<br />
want to benefit from the exploitation of others<br />
but will unthinkingly ignore the reality of how<br />
most clothes are made. Every day we are exposed<br />
to marketing on billboards, bus stops, shop<br />
windows, YouTube, Facebook, fashion blogs, and<br />
Instagram feeds. Our first thought is not ‘who<br />
made this?’, but ‘I want that’. It’s automatic, and<br />
that’s why it works. I choose to believe that my<br />
peers are not consciously deciding to fund a<br />
harmful industry, and that instead their choices<br />
simply reflect a lack of opportunity to consider<br />
their purchases. Here is said opportunity. Think<br />
carefully and buy ethically, so as to avoid a fashion<br />
faux-pas that’s more than just embarrassing—<br />
one that results in child slavery, abysmal wages<br />
and factory collapses causing thousands of<br />
deaths. If you would like to join me in protesting<br />
an industry that fuels the maltreatment and<br />
exploitation of others, then read on. This is my<br />
manifesto to fashion, and all the illnesses, injuries<br />
2
and deaths that it can cause when not held<br />
accountable.<br />
Do no harm<br />
The famous, perhaps trite,<br />
Hippocratic oath often comes to<br />
mind when considering the part<br />
that many medical students have<br />
played in the illnesses inflicted on<br />
sweatshop workers. It is a turn of<br />
phrase strongly associated with<br />
the medical profession, and one<br />
that most doctors and medical<br />
students take very seriously.<br />
While much has changed since<br />
the oath was created 2,500 years ago, human<br />
nature is still very much the same. This oath is<br />
important because it sets clear boundaries for<br />
minimum decency. To paraphrase Hippocrates,<br />
—‘Guys, I know you’re busy and all, but at least<br />
don’t give Bangladeshi women gastric ulcers and<br />
deprive them of food and sleep for days on end.’<br />
Bangladeshi sweatshop workers receive one of<br />
the lowest minimum wages in the world,[1] and<br />
women often feel obliged to prostitute themselves<br />
at work for extra money.[2] To help understand<br />
how severely impoverished they are, let’s take into<br />
account their average monthly wage, 3000 taka,<br />
which is approximately $50 Australian Dollars.<br />
Working 16 hours a day for 7 days a week, they<br />
have made the shirt on your back for 10 cents an<br />
hour. For an extra 7 cents an hour, they would<br />
have enough to meet the “living wage”,[3] defined<br />
as “the minimum required to provide a family with<br />
shelter, food and education”.[3] If you add on the<br />
other burdens associated with sweatshops; the<br />
cramped living, lack of maternity care, and risk of<br />
silicosis from all the sand blasting so your denim<br />
can have that worn aesthetic, Hippocrates would<br />
be turning in his grave.[4]<br />
No cause justifies the deaths of innocent<br />
people<br />
Averting the deaths of innocent civilians<br />
seems like another no-brainer, but in a globally<br />
reported disaster in April 2013, an eight-story<br />
sweatshop in Dhaka, Bangladesh, collapsed,<br />
killing over a thousand people and injuring over<br />
two thousand.[5] The sweatshop supplied clothes<br />
to international brands such as Primark and H&M.<br />
‘Our first<br />
thought is not<br />
who made this,<br />
but I want that’<br />
[5, 6] While this disaster was widely discussed, it is<br />
one of many examples of the deaths inflicted on<br />
Bangladeshi workers. Another 7 deadly accidents<br />
were reported to have occurred in Bangladesh<br />
between 2005 and 2015.[7] An<br />
example of the response from<br />
companies involved is the one<br />
provided by H&M after the Rana<br />
Plaza collapse. “It is important<br />
to remember that this disaster<br />
is an infrastructure problem in<br />
Bangladesh and not a problem<br />
specific to the textile industry”.<br />
[8] This response shifts the blame<br />
to a poverty-stricken country and<br />
should not absolve them from<br />
participating in the exploitation of Bangladeshi<br />
workers. Although these disasters may seem far<br />
away from our comparatively comfortable lives,<br />
the deplorable crimes committed by the fashion<br />
industry are being committed by the fashion<br />
industry in our names. Many of the clothing<br />
brands worn by my peers here in Australia<br />
have been remonstrated for their manufacture<br />
practices, including Tigerlily, UNIQLO, Gorman,<br />
Ralph Lauren, Lacoste, Boohoo, and Dotti.[9]<br />
Choosing which pretty dress or flash new suit to<br />
buy for the next ball can seem like a life or death<br />
situation, but instead of only stressing over which<br />
looks best, also ask yourself where and how it<br />
was made. There are actual lives at stake, not just<br />
social ones, and they are lives that you can help to<br />
save simply by asking the right questions.<br />
Practice what you preach<br />
Do what your favourite soul singer tells you to<br />
do and “Practice What You Preach” (Barry White,<br />
1994). How could you resist that deep baritone<br />
anyway? Sustainable fashion is generally seen as<br />
an ethical “thumbs up”, and yet so many people<br />
don’t practice it. There are a range of reasons that<br />
beliefs may not necessarily transfer to action, but<br />
the difficulty in keeping track of which brands<br />
treat their workers fairly seems to be a key one.<br />
One way to combat this challenge is to refer to<br />
an organisation that conveniently does it for you,<br />
such as Ethical Clothing Australia (ECA), which<br />
maps the local supply chain of brands to ensure<br />
the fair treatment of clothing workers. It provides<br />
a list of those brands which provide fair wages<br />
and decent living conditions, and its website lists<br />
A Kmart t-shirt‘s $3 price tag may be appealing to some, but<br />
their supply chain is untraceable and the workers receive a<br />
“minimum wage”, less than a “living wage”, the amount required<br />
to meet basic costs of living.<br />
3
these brands for your perusal. Some included<br />
brands are Cue, Manning Cartell, Thurley, Scanlan<br />
Theodore and Nobody.[10] As a general rule,<br />
however, it helps to ask if the price tag on an item<br />
really reflects the amount of work that went into<br />
making it.[11] A Kmart t-shirt‘s $3 price tag may<br />
be appealing to some, but their supply chain is<br />
untraceable and the workers receive a “minimum<br />
wage”, less than a “living wage”, the amount<br />
required to meet basic costs of living.[11] When<br />
considering price, it is obviously very important<br />
to acknowledge that not everyone can afford to<br />
pay for organic, handmade clothes. Some ways<br />
to overcome this include participating in the<br />
events run by charities like Fashion Revolution<br />
that work at raising awareness, shopping secondhand<br />
so that your money does not go directly to<br />
exploitative companies, learning to make your<br />
own clothes and writing to companies to put<br />
pressure on them to subscribe to ethical practice.<br />
[<strong>12</strong>] Go on, make Barry proud.<br />
There are alternatives to supporting exploitative<br />
fashion labels. Protesting the unethical choices<br />
of the fashion industry doesn’t mean you have<br />
to look like a hessian sack. Fashion is about<br />
making you feel like your best self, which is hard<br />
to accomplish when your new look endorses<br />
an industry that is directly responsible for the<br />
illnesses, injuries and deaths of women and<br />
children from third world countries. Next time<br />
you’re worried about committing a fashion fauxpas<br />
at Med Ball, remember your commitment to<br />
improving the lives of others. That commitment<br />
shouldn’t just remain within the confines of the<br />
hospital.<br />
Acknowledgements<br />
None<br />
Photo credit<br />
Ricardo Gomez Angel, accessed from https://<br />
unsplash.com/photos/rNXy6ngoyQ0<br />
Conflict of interest<br />
None declared<br />
Correspondence<br />
alar9706@uni.sydney.edu.au<br />
References<br />
1. International Labour Organisation, Characteristics<br />
of minimum wage setting system and minimum wage<br />
levels, [Internet]. Available from: https://www.ilo.org/<br />
wcmsp5/groups/public/---asia/---ro-bangkok/documents/<br />
genericdocument/wcms_223988.pdf, (accessed 2 September<br />
<strong>2018</strong>)<br />
2. Inter Press Service News Agency, Women Suffer Most in<br />
Garment Sweatshops in Bangladesh, [Internet], 1998. Available<br />
from: http://www.ipsnews.net/1998/<strong>12</strong>/labour-bangladeshwomen-suffer-most-in-garment-sweatshops/,<br />
(accessed 25<br />
August <strong>2018</strong>).<br />
3. War on Want, Sweatshops in Bangladesh [Internet].<br />
Available from: http://www.waronwant.org/sweatshopsbangladesh<br />
(accessed 20 March 2017).<br />
4. Akgun M, Araz O, Ucar EY, Karaman A, Alper F,<br />
Gorguner M, et al. Silicosis Appears Inevitable Among Former<br />
Denim Sandblasters: A 4-Year Follow-up Study. Chest.<br />
2015;148(3):647-54.<br />
5. The Independent, Bangladesh factory collapse: 41<br />
charged over deadly Rana Plaza tragedy, [Internet], 2015.<br />
Available from: http://www.independent.co.uk/news/world/<br />
asia/bangladesh-factory-collapse-41-charged-over-deadlyrana-plaza-tragedy-a6781876.html,<br />
(accessed 22 March 2016).<br />
6. Clean Clothes Campaign, Evaluation of H&M<br />
Compliance with Safety Action Plans for Strategic Suppliers<br />
in Bangladesh, [Internet], 2015. Available from: https://<br />
cleanclothes.org/resources/publications/hm-bangladeshseptember-2015.pdf,<br />
(accessed 25 August <strong>2018</strong>).<br />
7. CBC, Timeline: Deadly factory accidents in Bangladesh,<br />
[Internet]. Available from: http://www.cbc.ca/news2/<br />
interactives/timeline-bangladesh/, (accessed 22 March 2016).<br />
What you need to know:<br />
• The fast fashion industry is responsible for illnesses,<br />
injuries and deaths of sweatshop workers internationally.<br />
• Workers live in cramped living conditions, do not have<br />
access to maternity care, receive exploitative wages and are<br />
exposed to occupational hazards ranging from silicosis to<br />
factory collapses.<br />
• The ubiquitous nature of fast fashion makes it particularly<br />
difficult to forgo, however.<br />
• This article aims to raise awareness of the issue and outline<br />
some simple steps that we can take to minimise the amount<br />
we each contribute to this harmful industry.<br />
4
8. Business and Human Rights Resource Centre, Response by<br />
H&M: Rana Plaza factory collapse in Bangladesh; over 1100 dead,<br />
[Internet], 2013. Available from: https://business-humanrights.<br />
org/sites/default/files/media/documents/company_responses/<br />
h&m-response-re-bangladesh-building-collapse.pdf, (accessed<br />
20 March 2017)<br />
9. Baptist World Aid, The <strong>2018</strong> Ethical Fashion Report,<br />
[Internet]. Available from: https://baptistworldaid.org.au/<br />
resources/<strong>2018</strong>-ethical-fashion-report, (accessed 25 August <strong>2018</strong>)<br />
10. Ethical Clothing Australia, Brands, [Internet], 2016, http://<br />
ethicalclothingaustralia.org.au/brands/, (accessed 20 March 2017)<br />
11. Choice, Ethical clothing, [Internet], 2014. Available from:<br />
https://www.choice.com.au/shopping/everyday-shopping/<br />
clothing/articles/ethical-clothing#ethically, (accessed 22 March<br />
2016).<br />
<strong>12</strong>. Independent, Katharine Hamnett interview: How to shop<br />
ethically on a student budget, [Internet], 2014. Available from:<br />
www.independent.co.uk/student/student-life/katharine-hamnettinterview-how-to-shop-ethically-on-a-student-budget-9882406.<br />
html, (accessed 22 March 2016).<br />
5
Exploring the ethics and legality of conducting clinical<br />
trials in developing nations<br />
Feature article<br />
Rosemary B Kirk<br />
Rosemary B Kirk is a fourth year medical student at the University of New<br />
South Wales. She has an interest in research and bioethics, and the point<br />
where the two intersect.<br />
Introduction<br />
The number of clinical trials conducted in<br />
developing countries has increased dramatically<br />
in recent decades due to globalisation and<br />
increased need for trial subjects. For example,<br />
between 2002 and 2007 the number of United<br />
States (US) sponsors conducting pharmaceutical<br />
research abroad increased by 15% annually,<br />
while US-based trials decreased by 5.5%.[1] All<br />
trials involving human subjects require ethical<br />
discussion, and this is of particular importance in<br />
developing nations, where risk of exploitation is<br />
high. In this article I will describe the legislation<br />
surrounding these trials, summarise the benefits<br />
of clinical trials to developing nations and<br />
researchers, analyse the ethical issues raised<br />
by this practice through a principles-based and<br />
utilitarian lens, and discuss how future legislation<br />
could align the potential benefits of these trials<br />
with reality.<br />
Legislation surrounding clinical trials<br />
To understand why clinical trials in developing<br />
countries are conducive to exploitation, the<br />
issues with the legislation in place must first be<br />
understood.<br />
International<br />
Numerous international bodies have created<br />
documents outlining clinical trial guidelines. One<br />
of the most commonly referenced documents<br />
is the Declaration of Helsinki (DoH), developed<br />
and regularly updated by the World Medical<br />
Association. International guidelines such as this<br />
are not legally binding, but are referred to in the<br />
legislation of many countries.[2]<br />
These international guidelines have<br />
been criticised for being vague and thereby<br />
allowing researchers to circumvent their<br />
recommendations.[3] For example, the DoH<br />
states that new interventions must be tested<br />
against the current best intervention, that<br />
researchers should make provisions for posttrial<br />
access to their intervention, and that<br />
medical research on a group is only justified if<br />
6
it is responsive to their health needs.[4] However,<br />
the DoH lists circumstances in which placebo use<br />
is acceptable, does not specify the duration of<br />
availability or price of the intervention post-trial,<br />
and does not define how significant a health need<br />
must be for a community to justify participation<br />
in a trial.<br />
Developed nations<br />
Developed nations have regulations to<br />
protect subjects in trials within their country that<br />
are enforced by ethics committees. However,<br />
depending on who is funding the research, such<br />
regulations do not always have to be followed<br />
when conducting research internationally.[5] It<br />
can also be problematic to apply laws from one<br />
culture to another. For example, in<br />
the US, sponsors do not have to<br />
compensate subjects for treatment<br />
of research-related injuries, but<br />
this cannot reasonably be applied<br />
to nations where subjects cannot<br />
afford treatment.[6]<br />
Developing nations<br />
Developing nations are less<br />
likely to have established and<br />
financially-supported clinical trial<br />
regulation, and the increase in<br />
clinical trials in developing nations<br />
in recent years has overwhelmed<br />
existing ethical review systems.[7]<br />
This makes it easy for researchers<br />
to avoid investigation, and a 2004<br />
study found that 44% of studies in developing<br />
nations did not undergo any review from the<br />
country in which they took place.[8]<br />
Arguments for clinical trials in developing<br />
countries<br />
For companies<br />
The advantages for companies of conducting<br />
clinical trials in developing countries are<br />
numerous. Costs are significantly reduced as a<br />
result of lower salaries, cheaper facilities, and less<br />
time being required to receive approval for a trial.<br />
[9] Participant recruitment is also easier, due to<br />
the higher prevalence of diseases and paucity of<br />
treatment options.[10] Finally, subjects are less<br />
likely to have received prior treatment, increasing<br />
result significance.[2]<br />
For communities<br />
While it can be easy to assume that clinical trials<br />
in developing nations are inherently exploitative,<br />
these trials are not without their benefits to local<br />
communities. Trials provide pharmaceuticals<br />
to people who may otherwise have extremely<br />
limited access, and if the recommendations made<br />
in the DoH are implemented, these communities<br />
may have continued access to the drugs being<br />
‘...44% of<br />
studies in<br />
developing<br />
nations did not<br />
undergo any<br />
review from the<br />
country in which<br />
they took place’<br />
tested.[11] Furthermore, through conducting<br />
clinical trials, researchers can provide equipment<br />
and knowledge to advance local research, and<br />
can boost local economies.[<strong>12</strong>]<br />
Ethical perspectives<br />
If research is conducted ethically and following<br />
international guidelines, it is possible for all of the<br />
benefits described above to be realised. However,<br />
as long as clinical trials in developing countries<br />
are not properly policed, there are ethical issues<br />
implicit in this practice and a risk of exploitation.<br />
While there are countless ethical issues to be<br />
considered in this area, I will focus on the issues of<br />
informed consent, the dangers of trials, placebo<br />
use, testing of interventions that<br />
target health needs, and post-trial<br />
availability of interventions. These<br />
will be analysed using a principlesbased<br />
and a utilitarian lens.<br />
Autonomy<br />
Autonomy describes a state<br />
in which individuals are free to<br />
make their own decisions; one<br />
consequence of the principle of<br />
autonomy is informed consent.<br />
To make decisions, people must<br />
be provided with the relevant<br />
information in a form they can<br />
understand.[13] Informed consent<br />
has particular relevance for trials<br />
in developing nations, because<br />
gaining consent requires understanding local<br />
languages and analogies, and obtaining written<br />
consent can be difficult in the context of low<br />
education rates.[14,15] Additionally, in many<br />
communities it is essential to also obtain consent<br />
from elders, religious leaders, or heads of families.<br />
[16] Thus, in order for clinical trials in developing<br />
countries to be considered ethical from the<br />
perspective of autonomy, researchers must show<br />
cultural awareness in acquiring informed consent.<br />
Beneficence and non-maleficence<br />
Non-maleficence is the principle that actions<br />
should not expose individuals to unnecessary<br />
harm, while beneficence describes acting in a<br />
manner that benefits others.[13] In any clinical<br />
trial there is potential for significant harm to<br />
come to study subjects. This is particularly true<br />
when clinical trials are poorly regulated. For<br />
example, up to 2,644 people died in clinical<br />
trials of 475 new drugs over a 7-year period in<br />
India, with the majority of these trials being<br />
conducted by international sponsors.[17] In the<br />
context of murky international legislation and<br />
the potential for negligent trial structure and<br />
administration, such deaths can be considered<br />
a violation of the principle of non-maleficence<br />
by the researchers. Conversely, clinical trials can<br />
7
also be a force for beneficence in developing<br />
nations through the provision of medication and<br />
research infrastructure, as previously described.<br />
It is thus important that the potential harms and<br />
benefits of any trial to a community be carefully<br />
considered in order to maximise both principles<br />
of beneficence and non-maleficence.<br />
A further ethical issue relating to beneficence<br />
and non-maleficence is the use of placebos in<br />
clinical trials, a pertinent case study being the<br />
1994 African Zidovudine trials. These trials tested<br />
Zidovudine as a means of preventing vertical<br />
transmission of HIV, with comparison to control<br />
groups who received a placebo.[18] During<br />
the trial, many women in the control group<br />
transmitted HIV to their offspring. This violates<br />
the principle of beneficence, as researchers did<br />
not act to benefit all trial subjects (which could<br />
have been achieved by giving the control group<br />
an existing intervention). Whether or not this<br />
violates the principle of non-maleficence depends<br />
on how harm is defined. If harm requires an<br />
individual to be worse-off relative to a baseline,<br />
then this placebo use could be considered ethical<br />
in a nation where women otherwise receive<br />
no treatment.[10,19] However, this creates a<br />
double standard for developing countries, as<br />
using a placebo when there is existing treatment<br />
would be unethical in developed nations, as per<br />
recommendations established in the DoH. Views<br />
on placebos from this perspective, therefore, may<br />
vary.<br />
Justice<br />
The principle of justice involves fair distribution<br />
of scarce resources and respect for personal<br />
rights and laws.[20] Trials in developing countries<br />
are often for ailments primarily affecting<br />
developed nations, such as overactive bladder<br />
and allergic rhinitis, rather than for diseases that<br />
disproportionately affect developing countries.<br />
[1] People in developing nations are therefore<br />
assuming the risks of research while receiving little<br />
benefit. This practice is possible because there are<br />
many health needs in developing nations and, as<br />
previously stated, the DoH does not specify how<br />
important a health need must be for it to be an<br />
appropriate research target.[21] From a justice<br />
perspective, in order for a trial to be ethical it<br />
should target a health priority, not just a health<br />
issue present in a community. If this principle is<br />
followed, clinical trials may become a means of<br />
combatting global healthcare inequalities; indeed,<br />
as it stands today, 90% of the global healthcare<br />
budget targets illnesses responsible for only 10%<br />
of the global disease burden.[22]<br />
Another issue pertaining to the principle<br />
of justice is continued access to interventions<br />
post-trial. Basic medications are often absent<br />
or expensive in developing countries; therefore,<br />
continuing to offer treatments after a trial ends<br />
is one way of fighting this distributive injustice,<br />
especially if the intervention is offered to a wider<br />
community and the researchers are allied with<br />
broader access programmes.[11]<br />
Utilitarianism<br />
Utilitarianism deems actions good if such<br />
actions maximise the amount of good for<br />
a maximum number of people.[13] Using a<br />
utilitarian lens, it can be argued that since clinical<br />
trials in developing countries are mutually<br />
beneficial, imposing further constraints is not<br />
justified.[23] For example, if placebo use was not<br />
permitted in the African Zidovudine trials, the trial<br />
may not have been conducted, meaning no one<br />
would receive treatment.<br />
In the context of extreme utilitarianism, it can<br />
even be argued that all clinical trials in developing<br />
countries are ethically justifiable because the<br />
results can potentially help many more people<br />
than might be harmed in the trial process.<br />
Utilitarianism thus provides a very different<br />
overall view of clinical trials in developing<br />
countries than a principles-based perspective. In<br />
practice, the views of most ethical theorists and<br />
international guidelines align with a principlesbased<br />
perspective, while some developed nations<br />
follow the utilitarian perspective and favour<br />
scientific arguments and economic advantages<br />
over ethical concerns for people in developing<br />
countries.[24]<br />
Proposed future changes<br />
It is evident that the current guidelines and<br />
legislation surrounding international clinical<br />
trials are inadequate to protect trial subjects<br />
from exploitation. Because of deficiencies in<br />
international legal capacity and infrastructure<br />
in developing nations, the responsibility for<br />
protecting subjects of clinical trials in developing<br />
countries must fall to developed nations. Examples<br />
of beneficial changes to current legislation<br />
include adjusting laws to be culturally appropriate<br />
for developing communities,[24] enforcing<br />
governments to commit a portion of tax revenue<br />
to research that is responsive to the health<br />
priorities of developing countries,[21] and having<br />
governments provide incentives to support health<br />
policy improvement and appropriate research<br />
practices in developing nations.[25] However,<br />
such legislation is far from being realised, and is<br />
unlikely to be implemented provided that current<br />
legislation remains beneficial to developed<br />
nations and wealthy researchers.<br />
Conclusion<br />
There are many layers of legislation to be<br />
considered when conducting a clinical trial in a<br />
8
developing nation, with considerable potential<br />
for contradiction or legislative gaps. Trials can<br />
therefore result in exploitation, and require<br />
numerous ethical issues to be considered.<br />
Exploring these issues using a principles-based<br />
perspective reinforces the need for improved<br />
legislation surrounding trials; conversely,<br />
however, purely utilitarian perspectives support<br />
maintenance of the current status quo. While<br />
legislation is unlikely to change dramatically<br />
in the near future, many ethicists agree that if<br />
developed countries improve their legislation,<br />
clinical trials in developing nations can become<br />
a part of the solution to global health inequality,<br />
rather than part of the problem.<br />
Acknowledgements<br />
None<br />
Photo credit<br />
Louis Reed, accessed from https://unsplash.<br />
com/photos/pwcKF7L4-no<br />
Conflict of interest<br />
None declared<br />
Correspondence<br />
rosemary.kirk@unsw.edu.au<br />
References<br />
1. Glickman SW, McHutchison JG, Peterson ED, Cairns<br />
CB, Harrington RA, Califf RM, et al. Ethical and scientific<br />
implications of the globalization of clinical research. N Engl J<br />
Med. 2009;360(8):816-23<br />
2. Weigmann K. The ethics of global clinical trials. EMBO<br />
Rep. 2015;16(5):566-70<br />
3. Omonzejele PF. Is the codification of vulnerability in<br />
international documents a sufficient mechanism of protection<br />
in the clinical research ethics context?. Med Law. 2011;30:497-<br />
515<br />
4. World Medical Association. WMA Declaration of<br />
Helsinki – Ethical Principles for Medical Research Involving<br />
Human Subjects [Internet]. Geneva: The World Medical<br />
Association; <strong>2018</strong> July 9 [cited <strong>2018</strong> Aug 10]. Available from:<br />
https://www.wma.net/policies-post/wma-declaration-ofhelsinki-ethical-principles-for-medical-research-involvinghuman-subjects/<br />
5. Schneider JL. Professional codes of ethics: Their role<br />
and implications for international research. J Contemp Crim<br />
Justice. 2006;22(2):173-92<br />
6. Mamotte N, Wassenaar D, Singh N. Compensation for<br />
research-related injury in NIH-sponsored HIV/AIDS clinical<br />
trials in Africa. J Empir Res Hum Res Ethics. 2013;8(1):45-54<br />
7. Simpson B, Khatri R, Ravindran D, Udalagama T.<br />
Pharmaceuticalisation and ethical review in South Asia: <strong>Issue</strong>s<br />
of scope and authority for practitioners and policy makers. Soc<br />
Sci Med. 2015;131:247-54<br />
8. Hyder AA, Wali SA, Khan AN, Teoh NB, Kass NE, Dawson<br />
L. Ethical review of research: A perspective from developing<br />
country researchers. J Med Ethics. 2004;30(1):68-72<br />
9. Alemayehu C, Mitchell G, Nikles J. Barriers for conducting<br />
clinical trials in developing countries – a systematic review. Int<br />
J Equity Health. <strong>2018</strong>;17(1):37-47<br />
10. Botha M, Zeier MD. Clinical trials in developing<br />
countries: An overview. In: Stefan DC, editor. Cancer research<br />
and clinical trials in developing countries. Cham: Springer;<br />
2016. p.41-54<br />
11. Okpechi IG, Swanepoel CR, Venter F. Access to<br />
medications and conducting clinical trials in LMICs. Nat Rev<br />
Nephrol. 2015;11(3):189-94<br />
<strong>12</strong>. Lorenzo C, Garrafa V, Solbakk JH, Vidal S. Hidden risks<br />
associated with clinical trials in developing countries. J Med<br />
Ethics. 2010;36(20):111-5<br />
13. McNeill P, Torda A, Little JM, Hewson L. Ethics Wheel.<br />
Sydney: University of New South Wales. 2004.<br />
14. Emanuel EJ, Wendler D, Killen J, Grady C. What<br />
makes clinical research in developing countries ethical? The<br />
benchmarks of ethical research. J Infect Dis. 2004;189(5):930-7<br />
15. Diemert DJ, Lobato L, Styczynski A, Zumer M, Soares<br />
A, Gazzinelli MF. A comparison of the quality of informed<br />
consent for clinical trials of an experimental hookworm vaccine<br />
conducted in developed and developing countries. PLoS Negl<br />
Trop Dis. 2017;11(1):e0005327<br />
16. Martellet L, Sow SO, Diallo A, Hodgson A, Kampmann B,<br />
Hirve S, et al. Ethical challenges and lessons learned during the<br />
clinical development of a group A meningococcal conjugate<br />
vaccine. Clin Infect Dis. 2015;61(suppl 5):S422-7<br />
17. Mahapatra D. 2,644 died during clinical trial of drugs in<br />
7 years: Govt to SC. The Times of India. 2013 Apr 25 [cited <strong>2018</strong><br />
Aug 11]. Available from: https://timesofindia.indiatimes.com/<br />
india/2644-died-during-clinical-trial-of-drugs-in-7-years-<br />
Govt-to-SC/articleshow/19719175.cms<br />
18. Lavery JV, Grady C, Wahl ER, editors. Ethical issues in<br />
international biomedical research: a casebook. Oxford: Oxford<br />
University Press; 2007<br />
19. Hawkins JS, Emanuel EJ, editors. Exploitation and<br />
developing countries: The ethics of clinical research. Princeton:<br />
Princeton University Press; 2008<br />
20. Brizi AP, Filibeck U, Kangaspunta K, O’Neil AL.<br />
Biomedical research in developing countries: The promotion<br />
of ethics, human rights and justice. Italy: UNICRI; 2009<br />
21. Hughes RC. Justifying community benefit requirements<br />
in international research. Bioethics. 20<strong>12</strong>:28(8);397-404<br />
22. Wertheimer A. Rethinking the ethics of clinical research:<br />
widening the lens. Oxford: Oxford University Press; 2010<br />
23. Mitra AG. Off-shoring clinical research: Exploitation and<br />
the reciprocity constraint. Dev World Bioeth. 20<strong>12</strong>;13(3):111-8<br />
24. Garrafa V, Lorenzo C. Moral imperialism and multicentric<br />
clinical trials in peripheral countries. Cad Saude Publica.<br />
2008;24(10):2219-26<br />
25. Pratt B, Loff B. Health research systems:<br />
Promoting health equity or economic competitiveness?<br />
Bull World Health Organ. 20<strong>12</strong>;90(1):55-62<br />
9
The changing landscape of artifical neural stimulation and<br />
its introduction to the developing world<br />
Feature article<br />
Stephanie Kirkby<br />
Stephanie Kirkby is a medical student at Deakin University. Stephanie has<br />
previously completed a Bachelor of Science (Hons) at The University of<br />
Melbourne, majoring in Neuroscience, where she completed an Honours<br />
project with the National Vision Research Institute.<br />
With Commentary from Professor Michael<br />
Ibbotson<br />
The artificial electrical stimulation of neurons<br />
for the treatment of neurological disease and<br />
impairment is a well-established field that is<br />
undergoing rapid development in the treatment<br />
of diseases such as Parkinson’s disease,[1]<br />
obsessive compulsive disorder,[2] epilepsy,[3]<br />
as well as auditory and visual impairments using<br />
cochlear[4] and retinal implants.[5] The basic<br />
principle underlying these treatments arises from<br />
the inherent electrical excitability of all neurons<br />
in the body. By using electrical impulses to<br />
stimulate neurons, we can attempt to manipulate<br />
their functions. Thus, if there is a dysfunction in<br />
the firing of some neurons in the network, we can<br />
seek to replace them using electrodes. Generally,<br />
this is an area of research only being explored<br />
in the context of the developed world, however,<br />
particularly in the case of cochlear implants, there<br />
may soon be an evolving role for artificial neural<br />
stimulation in the developing world.<br />
To appreciate the potential of artificial neural<br />
stimulation, we must first appreciate the way<br />
in which the neural network operates. The<br />
communication between neurons within the<br />
brain is the primary control point of all human<br />
behaviours, ranging from the movement of our<br />
limbs to the control of our deepest thoughts and<br />
emotions. These neurons communicate via unique<br />
patterns of electrical activity within synchronous<br />
neuronal networks, which are composed<br />
of billions of cells. Different sensations and<br />
behaviours each depend upon a unique subset<br />
of neurons within this synchronous network for<br />
10
their function. For instance, the neurons recruited<br />
for vision differ in appearance, location, electrical<br />
signature, and distribution when compared<br />
to those required for hearing. However, when<br />
the health of these neurons is compromised,<br />
so too is their ability to produce these complex<br />
patterns of activity. Artificial neural stimulation<br />
takes advantage of the electrical potential of<br />
neurons, whose function is dependent upon<br />
the flow of charge from one cell to the next. By<br />
injecting such neurons with an electrical stimulus<br />
using electrodes, we can artificially generate new<br />
patterns of neuronal activity that can replace the<br />
role of any dysfunctional cells in the network.<br />
Bionic vision is still in its infancy but has made<br />
significant strides in the treatment of retinitis<br />
pigmentosa, the leading cause of inherited<br />
blindness.[6] There are also plans<br />
to utilise it for the treatment<br />
of macular degeneration, the<br />
leading cause of blindness<br />
in the developed world.[7] A<br />
United States Food and Drug<br />
Administration (FDA) approved<br />
model, developed by Second<br />
Sight in the USA, has already<br />
been implanted in hundreds of<br />
patients for the treatment of<br />
retinitis pigmentosa,[8] restoring<br />
‘functional vision’ to its recipients.<br />
Functional vision is significantly<br />
different from normal vision and<br />
relies on ‘phosphenes’ to produce<br />
visual percepts of the surrounding<br />
world.[9] Phosphenes are ‘spots’<br />
within the visual field that can be<br />
perceived as either light or dark,<br />
such that a recipient may be able<br />
to perceive a horizon, navigate a<br />
dining room table, or see obstacles<br />
on a street. Phosphene vision is<br />
distinct from normal vision, being<br />
unable to depict colour or fine detail, as well as<br />
being limited by the number of phosphenes that<br />
a patient can see. Each phosphene corresponds<br />
to an electrode that has been placed on the<br />
retina, so with more electrodes, the patient will<br />
be able to perceive more sections of the visual<br />
field distinctly. However, there are multiple<br />
limitations to achieving higher visual acuity with<br />
more electrodes within retinal prostheses such<br />
that phosphene vision remains ‘functional’ but<br />
rudimentary compared to normal human vision.<br />
Michael Ibbotson, Director of the National<br />
Vision Research Institute and Professor at The<br />
University of Melbourne believes that “the sky<br />
is the limit” when it comes to the potential of<br />
artificial neural stimulation. “Two key factors have<br />
driven the rapid expansion of bionics in recent<br />
years; the improvement of surgical techniques for<br />
‘Despite the difficulty<br />
inherent in reading a<br />
text with bionic vision,<br />
patients would prefer<br />
to utilise that sense,<br />
which otherwise would<br />
be lost to them, rather<br />
than opt for an easier<br />
means of reading such<br />
as an audiobook.’<br />
implantation and the increased biocompatibility<br />
of the materials used. Recent advances have<br />
made it possible to both record from and<br />
stimulate neurons in different areas of the brain.<br />
For instance, we could record sensory neural<br />
information from one part of the brain and then<br />
feed it back into motor neurons to emulate more<br />
natural movements of the body.”<br />
“However, in many cases although we do not<br />
perfectly replicate the original neural network’s<br />
function, there are still significant positive<br />
outcomes for patients psychologically to have a<br />
lost sense restored.[10, 11] Despite the difficulty<br />
inherent in reading a text with bionic vision,<br />
patients would prefer to utilise that sense, which<br />
otherwise would be lost to them, rather than<br />
opt for an easier means of reading such as an<br />
audiobook.” What has been<br />
restored for these patients<br />
is much more than their<br />
sight or their hearing, but<br />
rather a restoration of their<br />
sense of self.[11]<br />
According to Professor<br />
Ibbotson, it seems possible<br />
that the future of bionics<br />
may expand well beyond<br />
the medical world, stating<br />
that “once it becomes<br />
normal within medicine, it<br />
would not surprise me if<br />
bionics became cosmetic”.<br />
As the technology develops<br />
and becomes normalised<br />
as a treatment for various<br />
impairments and diseases,<br />
the public may eventually<br />
see an opportunity<br />
for self-improvement<br />
through artificial neural<br />
stimulation. For instance,<br />
breast implantation was originally developed for<br />
mastectomy patients before it became one of the<br />
most popular cosmetic surgeries of the modern<br />
world. [<strong>12</strong>] “If it were possible to improve memory<br />
function by selectively stimulating memory<br />
circuits at particular times, this could dramatically<br />
change the way in which students approached<br />
education, as well as in the treatment of memory<br />
disorders”. Although it seems closer to science<br />
fiction than reality, the cosmetic use of artificial<br />
neural stimulation, if it were realised, would<br />
have the potential to increase the profitability of<br />
this technology. If this were the case, it may be<br />
possible to fund its use in less developed regions,<br />
where it is currently unavailable.<br />
The expanding range of pathologies that can<br />
be treated by neural stimulation is promising,<br />
particularly for the developed world, but its<br />
11
implementation in the developing world is far more<br />
complex.[13] There are many obvious hurdles in<br />
utilising this technology beyond high-income<br />
countries. The first issue is the prioritisation of<br />
resources to ensure the greatest possible impact<br />
on public health outcomes. There are many other<br />
competing health priorities that require attention<br />
before advanced interventions to improve<br />
neurological health can be implemented.[14, 15]<br />
“The cochlear implant appears to be the<br />
exception to the rule” according to Professor<br />
Ibbotson. Since its initial clinical introduction<br />
for patients in 1985, the cochlear implant has<br />
undergone significant developments and is<br />
now widely utilised in the treatment of hearing<br />
impairment, particularly in paediatrics where its<br />
impact is more dramatic in younger brains due<br />
to increased neuroplasticity. The cochlear implant<br />
has also seen recent introductions into low and<br />
middle-income countries in South America,<br />
Egypt, India and China, where it has faced multiple<br />
ethical and practical challenges.[13] However,<br />
recent studies have shown that its use can remain<br />
cost-effective, even in regions where there is a<br />
scarcity of health resources.[13] This is largely due<br />
to both the use of low-cost materials and the high<br />
health benefit associated with hearing restoration<br />
in patients.<br />
The health priorities of patients also need to be<br />
aligned with access to neural implants, regardless<br />
of the product’s availability. If patients do not<br />
feel the need for such health interventions, then<br />
such interventions are unlikely to be utilised. For<br />
instance, the cochlear implant is still met with<br />
some resistance in the deaf community due to the<br />
fear of compromising their cultural identity. [16]<br />
Visual impairment is one such example<br />
where there is a significant variation between<br />
the priorities of the developing world and the<br />
developed world. In low-income countries,<br />
cataracts are the leading cause of blindness, [17]<br />
whilst in the developed world, the leading cause<br />
of blindness is age-related macular degeneration.<br />
[7] Naturally, there is a gap in the prioritisation of<br />
treatment availability where surgical intervention<br />
is a successful treatment for cataracts but remains<br />
difficult to deliver to disadvantaged regions of<br />
the world. The treatment of age-related macular<br />
degeneration and other degenerative retinal<br />
diseases has inspired the development of the<br />
bionic eye, but is less likely to be considered a<br />
treatment priority for the developing world until<br />
it becomes far more affordable.<br />
Global health priorities are consistently evolving<br />
to reflect the needs of the wider population.<br />
Although it may be in the distant future, the wider<br />
utility of artificial neural stimulation will remain<br />
unclear until the technology has sufficiently<br />
advanced. It will be important for patients to<br />
have an awareness and understanding of such<br />
technology in the future, so that it is more likely<br />
to be accepted as a potential treatment for future<br />
health initiatives.<br />
At a recent public forum, Professor Ibbotson<br />
also reported that one of the primary concerns<br />
of the public surrounding the use of neural<br />
implants was the potential for ‘mind control’. This<br />
demonstrates a significant gap in the public’s<br />
understanding of what artificial neural stimulation<br />
aims to achieve, as well as what it is capable of.<br />
The potential for this type of neural control is wellbeyond<br />
the capabilities of current technology,<br />
which aims to stimulate otherwise inactive local<br />
networks of the brain to restore a lost function<br />
such as vision or hearing.[18] However, these<br />
patient concerns are still important to consider if<br />
such technology is ever to be widely implemented<br />
in medicine in the future.<br />
The human brain is infinitely complex and<br />
research is only recently gaining significant<br />
momentum in our understanding of its function.<br />
The development of artificial neural stimulation<br />
is an expanding field for the treatment of<br />
degenerative neural diseases. Although this<br />
technology is in its infancy, it has enormous<br />
potential for public health outcomes in both the<br />
developed and developing worlds, which are yet to<br />
be fully realised. The range of pathologies treated<br />
with artificial neural stimulation is expanding as<br />
rapidly as our understanding of the brain itself,<br />
making the development of this research an<br />
important area to watch in the future of medicine.<br />
‘Although it may be in the distant future, the<br />
wider utility of artificial neural stimulation will<br />
remain unclear until the technology has sufficiently<br />
advanced. It will be important for patients to have an<br />
awareness and understanding of such technology in<br />
the future, so that it is more likely to be accepted as<br />
a potential treatment for future health initiatives.’<br />
<strong>12</strong>
Acknowledgements<br />
Commentary and revisions provided by Professor<br />
Michael Ibbotson.<br />
Photo credits<br />
Meo, accessed from https://www.pexels.<br />
com/photo/photo-of-head-bust-printartwork-724994/<br />
Conflict of interest<br />
Stephanie Kirkby is currently working with the<br />
National Vision Research Institute on a followup<br />
project relating to her Honours research with<br />
Professor Michael Ibbotson.<br />
Correspondence<br />
skirkby@deakin.edu.au<br />
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J, Akram H, Martinez-Torres I, et al. Long-term outcome of<br />
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disease using an MRI-guided and MRI-verified approach. J Neurol<br />
Neurosurg Psychiatry. 2014; 85: 1419-25<br />
2. Alonso P, Cuadras D, Gabriëls L, Denys D, Goodman W,<br />
Greenberg BD, et al. Deep brain stimulation for obsessivecompulsive<br />
disorder: a meta-analysis of treatment outcome and<br />
predictors of response. PloS one. 2015;10(7): e0133591<br />
3. Cukiert A, Cukiert CM, Burattini JA, Lima AM. Seizure<br />
outcome after hippocampal deep brain stimulation in a<br />
prospective cohort of patients with refractory temporal lobe<br />
epilepsy. Seizure. 2014;23(1):6-9.<br />
4. Mäki-Torkko EM, Vestergren S, Harder H, Lyxell B. From<br />
isolation and dependence to autonomy–expectations before and<br />
experiences after cochlear implantation in adult cochlear implant<br />
users and their significant others. Disability and rehabilitation.<br />
2015;37(6):541-7.<br />
5. Hadjinicolaou AE, Meffin H, Maturana MI, Cloherty SL,<br />
Ibbotson MR. Prosthetic vision: devices, patient outcomes<br />
and retinal research. Clinical & Experimental Optometry.<br />
2015;98(5):395-410.<br />
6. Hartong DT, Berson EL, Dryja TP. Retinitis pigmentosa.<br />
2006;368(9549):1795-809.<br />
7. Wong WL, Su X, Li X, Cheung CMG, Klein R, Cheng C-Y, et<br />
al. Global prevalence of age-related macular degeneration and<br />
disease burden projection for 2020 and 2040: a systematic review<br />
and meta-analysis. The Lancet Global Health. 2014;2(2):106-116<br />
8. Second Sight Announces Record Number of Argus II<br />
Retinal Prosthesis Systems Implants and Completes First-in-<br />
Human Orion Cortical Implant [press release]. California: Second<br />
Sight <strong>2018</strong>.<br />
9. Pérez Fornos A, Sommerhalder J, da Cruz L, Sahel JA,<br />
Mohand-Said S, Hafezi F, et al. Temporal properties of visual<br />
perception on electrical stimulation of the retina. Investigative<br />
Ophthalmology & Visual Science. 20<strong>12</strong>;53(6):2720-31.<br />
10. Duncan JL, Richards TP, Arditi A, da Cruz L, Dagnelie G,<br />
Dorn JD, et al. Improvements in vision related quality of life in<br />
blind patients implanted with the Argus II Epiretinal Prosthesis.<br />
Clinical and Experimental Optometry. 2017;100(2):144-50.<br />
11. Da Cruz L, Coley BF, Dorn J, Merlini F, Filley E, Christopher<br />
P, et al. The Argus II epiretinal prosthesis system allows letter and<br />
word reading and long-term function in patients with profound<br />
vision loss. British Journal of Ophthalmology. 2013;97:632-6<br />
<strong>12</strong>. Champaneria MC, Wong WW, Hill ME, Gupta SC. The<br />
evolution of breast reconstruction: a historical perspective. World<br />
journal of surgery. 20<strong>12</strong>;36(4):730-42.<br />
13. Fagan JJ, Tarabichi M. Cochlear implants in developing<br />
countries: practical and ethical considerations. Current opinion in<br />
otolaryngology & head and neck surgery. <strong>2018</strong>;26(3):188-9.<br />
14. Allegranzi B, Kilpatrick C, Storr J, Kelley E, Park BJ,<br />
Donaldson L, et al. Global infection prevention and control<br />
priorities <strong>2018</strong>–22: a call for action. The Lancet Global Health.<br />
2017;5(<strong>12</strong>):1178-80.<br />
15. Chao TE, Sharma K, Mandigo M, Hagander L, Resch SC,<br />
Weiser TG, et al. Cost-effectiveness of surgery and its policy<br />
implications for global health: a systematic review and analysis.<br />
The Lancet Global Health. 2014;2(6):334-45.<br />
16. Goldblat E, Most T. Cultural Identity of Young Deaf Adults<br />
with Cochlear Implants in Comparison to Deaf without Cochlear<br />
Implants and Hard-of-Hearing Young Adults. The Journal of Deaf<br />
Studies and Deaf Education. <strong>2018</strong>;23(3):228-39.<br />
17. Khairallah M, Kahloun R, Bourne R, Limburg H, Flaxman<br />
SR, Jonas JB, et al. Number of people blind or visually impaired<br />
by cataract worldwide and in world regions, 1990 to 2010.<br />
Investigative ophthalmology & visual science. 2015;56(11):6762-<br />
9.<br />
18. Lebedev MA, Nicolelis MA. Brain-machine interfaces:<br />
From basic science to neuroprostheses and neurorehabilitation.<br />
Physiological reviews. 2017;97(2):767-837.<br />
What you need to know:<br />
• The artificial electrical stimulation of neurons for the treatment<br />
of neurological disease and impairment is a well-established field<br />
that is undergoing rapid development in the treatment of disease.<br />
• The expanding range of pathologies that can be treated by<br />
neural stimulation is promising, particularly for the developed<br />
world, but its implementation in the developing world is far more<br />
complex.<br />
• According to Professor Michael Ibbotson of the National<br />
Vision Research Institute, the future of bionics may expand beyond<br />
the medical world and potentially be used cosmetically for selfimprovement.<br />
• Although this technology is in its infancy, it has enormous<br />
potential for public health outcomes in both the developed and<br />
developing worlds, which are yet to be fully realised.<br />
The<br />
Lancet.<br />
13
Pornography: the pyschological and neurological<br />
effects of a $97 billion industry<br />
Review article<br />
Bridie H Peters<br />
Bridie H Peters is a third year medical student at the University of New<br />
England. She’s far from impartial to a chocolate dusting on cappuccinos,<br />
a ripper sunset and some great evidence-based medicine.<br />
“<br />
Background<br />
The proliferation of the Internet has fostered<br />
a wild-fire growth of the pornography industry.<br />
[1] Pornography is more accessible and widely<br />
disseminated than ever before, accounting for<br />
a quarter of all internet searches and 1.5% of all<br />
websites.[2] However, this growth doesn’t come<br />
without concern. The cultivation of sexual abuse,<br />
misogyny and poor mental health are among some of<br />
the startling accusations made against this industry.<br />
[1,3,4] Given that 84% of Australian males and 23%<br />
of females aged 16-25 years use this media daily<br />
or weekly,[5] if these accusations hold water, they<br />
may have significant and widespread impacts. The<br />
following review aims to summarise the research on<br />
the health effects of pornography on its users.<br />
Compulsive pornography use and addiction<br />
There is considerable debate as to whether<br />
pornography has addictive potential and if it does,<br />
whether it is comparable to those of other addiction<br />
disorders (e.g. alcoholism, compulsive gambling).<br />
[6] These well-established addiction disorders are<br />
Abstract<br />
Aims: This review aims to summarise the research exploring the health effects of internet pornography<br />
on its users. It focuses on pornography’s addictive potential, impact on sexual behaviours and mental<br />
health.<br />
Methods: The relevant literature concerning the health effects of internet pornography was reviewed.<br />
Resources were sourced from databases such as PubMed and JSTOR.<br />
Results: This review finds significant evidence for the addictive potential of pornography, validating<br />
the consideration of pornography addiction as a clinical diagnosis. Pornography may also cultivate<br />
misogynistic beliefs, affect the sexual functioning of its users and have some role in promoting sexually<br />
aggressive behaviours. Poor mental health and pornography appear to have a bi-directional association.<br />
Conclusions: The potential health effects of pornography are extensive and well-established. Given<br />
the ubiquitous nature of this media, there may be significant clinical implications for these findings.<br />
”<br />
characterised by several common thought and<br />
behavioural patterns. These include but are not<br />
limited to: (a) perceived lack of control over the<br />
substance/ object of abuse; (b) adverse consequences<br />
from is use (e.g. relationship, social, work or school<br />
problems); (c) an inability to stop its use despite<br />
these negative consequences; and (d) preoccupation<br />
with the substance/ object of abuse.[7]<br />
These symptoms are being increasingly reported<br />
in patients who complain of pornography overuse. [6]<br />
Pornography addiction is not at present a formallyrecognised<br />
clinical disorder in the DSM-V or ICD-10,<br />
however, the prevalence of these findings has led to<br />
the widespread use of Compulsive Pornography Use<br />
as a working clinical diagnosis. Many of the studies<br />
mentioned in this paper have recruited patients<br />
suspected to have this disorder. There is no consensus<br />
on the definition of this disorder, but as with other<br />
addictions, the aforementioned thought patterns are<br />
characteristic[7]. The prevailing argument contesting<br />
the recognition of Compulsive Pornography Use as a<br />
clinical disorder is the thought that these symptoms<br />
reflect a high sex drive in certain populations and are<br />
not suggestive of a pathological addiction.[8]<br />
14
The cultivation of sexual abuse, misogyny and poor mental<br />
health are among some of the startling accusations made against<br />
this industry.[1,3,4] Given that 84% of Australian males and<br />
23% of females ages 16-25 use this media daily or weekly,[5]<br />
if these accusations hold water, they may have significant and<br />
widespread impacts.<br />
Due to this debate, researchers have attempted<br />
to draw direct comparisons between those with<br />
suspected Compulsive Pornography Use and those<br />
with addiction to substances where the disorder is<br />
better defined and established (e.g. alcohol). One<br />
of the hallmarks of a substance use disorder is an<br />
increased desire for a substance without proportional<br />
pleasure from its use.[6] On fMRI neuroimaging this<br />
can be visualised as decreased striatal responsiveness<br />
to dopamine as the brain becomes tolerant to its<br />
effects.[9] Very similar findings have been found in<br />
patients with suspected pornography addiction. Their<br />
desire for this media far exceeds the pleasurable<br />
effects it has on them[10] and fMRI changes<br />
resemble those in patients with other substance<br />
use disorders.[11] Studies have found reduced grey<br />
matter volume in the right caudate and dampened<br />
putamen activation in those who compulsively use<br />
pornography.[<strong>12</strong>] These patients are also likely to<br />
have escalating levels of pornography usage, which<br />
supports the theory that a tolerance to pornography<br />
can develop.[13]<br />
A predominant counter to these findings is that<br />
reduced striatal volume is a precondition for, not a<br />
result of increased pornography use.[<strong>12</strong>] This model<br />
argues that people with naturally lowered striatal<br />
volume require additional stimuli for dopaminergic<br />
responses. They are therefore more likely to consume<br />
large amounts of pornography. With this model,<br />
those with decreased striatal volume should be able<br />
to achieve the full pleasurable effects of pornography,<br />
even if more of it is needed.[<strong>12</strong>] However, there does<br />
not seem to be this expected positive dose-effect<br />
relationship between pornography use and pleasure.<br />
[10] Additionally, laboratory fMRI studies have shown<br />
that repeated viewing of sexual images can cause a<br />
down-regulation of the brain’s reward pathways.[14]<br />
This suggests pornography can play an active role<br />
in down-regulating the striatum. The dose-response<br />
relationship of this finding is yet to be established,<br />
and it remains unclear whether these findings are<br />
exclusive to high-volume users or those with other<br />
risk factors for addiction.<br />
Gender roles and sexual behaviour<br />
Another charge made against pornography is<br />
its potential to promote misogynistic attitudes and<br />
behaviours, particularly in males. In a review of 135<br />
studies on the topic, it was found that sexualised<br />
media, of which pornography was included, was<br />
directly associated with “sexist beliefs … and greater<br />
tolerance of sexual violence toward women” in males.<br />
[15] This media may play a role in cultivating views that<br />
support female objectification, patriarchal ideologies<br />
and permissiveness towards female harassment.<br />
[1] This association is greatest when pornography<br />
is accessed during early adolescence (<strong>12</strong>-14 years).<br />
[16] Longitudinal research in this area is lacking,<br />
therefore these findings may simply suggest that<br />
people with these views consume greater amounts of<br />
pornography as it reaffirms their beliefs. Additionally,<br />
if pornography is to have a role in promoting sexist<br />
attitudes, the extent to which these opinions go on<br />
to influence interactions with others is unclear and<br />
difficult to determine.<br />
The research attempting to establish the impact of<br />
pornography on sexual encounters is highly conflicted.<br />
A prevalent thought is that the violence depicted in<br />
its material desensitises viewers to sexual assault,<br />
increasing their propensity to commit sexual crimes.<br />
[17] This view is supported by findings that porn can<br />
increase acceptance of rape and sexual assault in<br />
males.[3,18] This influence on sexual violence seems<br />
to be greatest and perhaps limited to males with<br />
other risk factors for sexually aggressive behaviour.<br />
[1] These include: a history of family violence, a<br />
cultural upbringing promoting male dominance<br />
and toughness, attitudes accepting of violence and<br />
impersonal views of sex.[19] Pornography use in<br />
these high-risk individuals has been associated with<br />
an increased prevalence of forced vaginal, oral and<br />
digital penetration, sexually aggressive remarks and<br />
sex with animals.[1] This research challenges the<br />
argument of a cathartic role for pornography – that<br />
its usage can reduce the prevalence of sexual crimes<br />
committed in males as these sexual impulses are<br />
somewhat acted upon through pornography usage.<br />
The active role of pornography usage in promoting<br />
sexual assault is well-established in people with<br />
other risk factors for sexual assault, however, the<br />
causal link between pornography and sexual assault<br />
in most users is less strongly established and highly<br />
debated.[20] Therefore, pornography may play a role<br />
in fostering and validating attitudes that predispose<br />
some men to rape women, however, it may have little<br />
to no impact in males with no other risk factors for<br />
sexually aggressive behaviour.[1] There are many<br />
15
arriers to research into this question, not least the<br />
underreporting of sexual assault and the ubiquitous<br />
nature of this media.<br />
While pornography may have a limited role in<br />
promoting sexually aggressive behaviour in most<br />
men, lowered libido and erectile dysfunction are<br />
widespread in pornography users.[21] In a study<br />
of adolescent males, 16% of those who consumed<br />
pornography more than once weekly reported<br />
low sexual desire, compared to 0% of those who<br />
did not.[22] Other sexual performance problems<br />
associated with pornography use include difficulty<br />
orgasming, decreased enjoyment of sexual intimacy,<br />
less sexual and relationship satisfaction and a<br />
preference for pornography over a sexual partner.<br />
[23] Erectile dysfunction is also strongly associated<br />
with pornography use and when present, often<br />
occurs during intimate sexual relationships, but<br />
not to sexually explicit material.[10] Males who use<br />
pornography to stimulate sexual desire likely partially<br />
account for these findings. However, cessation of<br />
pornography use has on numerous accounts been<br />
recorded as an effective treatment for patients with<br />
sexual dysfunction, suggesting it does also play a<br />
causal role in this condition.[24,25]<br />
One longitudinal study has also found that<br />
pornography usage has a statistically significant<br />
role in predicting poor marital quality. Pornography<br />
usage was found not only to be a product of<br />
martial dissatisfaction, but a causal factor for such<br />
dissatisfaction. This media was the second greatest<br />
predictor of poor marital quality in the study,<br />
following only marital quality at the commencement<br />
of the study. These effects increase with frequency<br />
of pornography use and seemed to only apply to<br />
husbands who use pornography and not to wives.<br />
[26]<br />
Mental health<br />
With our society’s increasing interest in mental<br />
health, pornography’s impact in this area is being<br />
heavily researched. Pornography usage is strongly<br />
associated with mental health disorders, loneliness,<br />
poor self-esteem and reduced quality of life.<br />
[5,27,28,29] An Australian study of 914 adolescents<br />
found that those who reported mental health<br />
problems in the last 6 months were 52% more<br />
likely to watch pornography at least once weekly<br />
than those who did not.[5] Masturbation to internet<br />
pornography has also been strongly associated<br />
with dissatisfaction in offline life and feelings of<br />
poor social support.[29] Pornography may play<br />
a causal role in this relationship, but equally, it<br />
may be a means by which adolescents aim to aid<br />
feelings of loneliness. Exploring the causal nature of<br />
this relationship, a study published earlier this year<br />
found that intentional exposure to pornography in<br />
adolescence was a predictive factor for depression<br />
and low self-esteem in later life.[30] On the other<br />
hand, a longitudinal study has also found that low<br />
self-esteem and depressive feelings in adolescent<br />
males are predictive of compulsive pornography<br />
use.[31] The extent to which poor mental health and<br />
pornography encourage each other is unclear. The<br />
increasing ubiquity of this media makes controlled<br />
longitudinal trials in this field difficult to conduct.<br />
Additional research exploring the therapeutic<br />
benefits of pornography cessation in patients with<br />
mental health disorders would be of great clinical<br />
benefit.<br />
Conclusion<br />
While much of the research exploring the health<br />
impacts of pornography is still inconclusive, there is<br />
still substantial and warranted concern surrounding<br />
this media. This field would greatly benefit from<br />
additional longitudinal studies which further clarify<br />
the causal role of pornography in promoting the<br />
health issues addressed above. The prolific use of this<br />
media does serve as a barrier to controlled studies<br />
in this field, but also stresses the need for further<br />
research, given the extensive clinical implications<br />
such findings may have. Additionally, this industry<br />
has transformed substantially this century with the<br />
proliferation of the internet, and the full impacts of<br />
this may yet be apparent.<br />
Acknowledgements<br />
Koshy Matthew & Tim Hanna.<br />
Conflicts of interest<br />
None declared.<br />
Correspondence<br />
bpeters7@myune.edu.au<br />
An Australian study of 914 adolescents found that<br />
those who reported mental health problems in the last<br />
6 months were 52% more likely to watch pornography<br />
at least once weekly than those who did not.[5]<br />
16
References<br />
1. Owens E, Behun R, Manning J, Reid R. The Impact of Internet<br />
Pornography on Adolescents: A Review of the Research. Sexual<br />
Addiction & Compulsivity. 20<strong>12</strong>;19(1-2):99-<strong>12</strong>2.<br />
2. Papadopoulos L. Sexualisation of Young People [Internet].<br />
Home Office; 2010 p. 45. Available from: http://webarchive.<br />
nationalarchives.gov.uk/20100408115835/http://www.<br />
homeoffice.gov.uk/documents/Sexualisation-young-people.html<br />
3. Allen M, Emmers T, Gebhardt L, Giery M. Exposure<br />
to Pornography and Acceptance of Rape Myths. Journal of<br />
Communication. 1995;45(1):5-26.<br />
4. Weaver J, Weaver S, Mays D, Hopkins G, Kannenberg W,<br />
McBride D. Mental and Physical Health Indicators and Sexually<br />
Explicit Media Use Behavior by Adults. The Journal of Sexual<br />
Medicine. 2011;8(3):764-772.<br />
5. Lim M, Agius P, Carrotte E, Vella A, Hellard M. Young<br />
Australians’ use of pornography and associations with sexual risk<br />
behaviours. Australian and New Zealand Journal of Public Health.<br />
2017;41(4):438-443.<br />
6. Love T, Laier C, Brand M, Hatch L, Hajela R. Neuroscience of<br />
Internet Pornography Addiction: A Review and Update. Behavioral<br />
Sciences. 2015;5(3):388-433.<br />
7. Doornwaard S, van den Eijnden R, Baams L, Vanwesenbeeck<br />
I, ter Bogt T. Lower Psychological Well-Being and Excessive Sexual<br />
Interest Predict Symptoms of Compulsive Use of Sexually Explicit<br />
Internet Material Among Adolescent Boys. Journal of Youth and<br />
Adolescence. 2015;45(1):73-84.<br />
8. David L. Your Brain on Porn - It’s NOT Addictive [Internet].<br />
Psychology Today. 2013 [cited 27 August <strong>2018</strong>]. Available from:<br />
https://www.psychologytoday.com/au/blog/women-whostray/201307/your-brain-porn-its-not-addictive<br />
9. Allen M, Emmers T, Gebhardt L, Giery M. Exposure<br />
to Pornography and Acceptance of Rape Myths. Journal of<br />
Communication. 1995;45(1):5-26.<br />
10. Voon V, Mole T, Banca P, Porter L, Morris L, Mitchell S<br />
et al. Neural Correlates of Sexual Cue Reactivity in Individuals<br />
with and without Compulsive Sexual Behaviours. PLoS ONE.<br />
2014;9(7):e102419.<br />
11. Volkow N, Koob G, McLellan A. Neurobiologic Advances<br />
from the Brain Disease Model of Addiction. New England Journal<br />
of Medicine. 2016;374(4):363-371.<br />
<strong>12</strong>. Kühn S, Gallinat J. Brain Structure and Functional<br />
Connectivity Associated With Pornography Consumption. JAMA<br />
Psychiatry. 2014;71(7):827.<br />
13. 4th International Conference on Behavioral Addictions<br />
February 20–22, 2017 Haifa, Israel. Journal of Behavioral Addictions.<br />
2017;6(Supplement 1):1-74.<br />
14. Banca P, Morris L, Mitchell S, Harrison N, Potenza M, Voon<br />
V. Novelty, conditioning and attentional bias to sexual rewards.<br />
Journal of Psychiatric Research. 2016;72:91-101.<br />
15. Ward L. Media and Sexualization: State of Empirical<br />
Research, 1995–2015. The Journal of Sex Research. 2016;53(4-<br />
5):560-577.<br />
16. Brown J, L’Engle K. X-Rated Sexual Attitudes and Behaviours<br />
Associated With U.S. Early Adolescents’ Exposure to Sexually<br />
Explicit Media. Journal of Geriatric Psychiatry and Neurology.<br />
2009;36(1):<strong>12</strong>9-151.<br />
17. The Concerning Connection Between Sex Crimes And Porn<br />
[Internet]. Fight the New Drug. <strong>2018</strong> [cited 29 June <strong>2018</strong>]. Available<br />
from: https://fightthenewdrug.org/the-disturbing-link-betweenporn-and-sex-crimes/<br />
18. Flood M. Youth and Pornography in Australia [Internet].<br />
Canberra: The Australia Institute; 2003. Available from: https://<br />
eprints.qut.edu.au/103421/1/__qut.edu.au_Documents_<br />
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Australia%2003.pdf<br />
19. Malamuth, N., & Huppin, M. (2005). Pornography and<br />
teenagers: The importance of individual differences. Adolescent<br />
Medicine, 16, 315–326.<br />
20. Ferguson C, Hartley R. The pleasure is momentary…<br />
the expense damnable?. Aggression and Violent Behavior.<br />
2009;14(5):323-329.<br />
21. Park B, Wilson G, Berger J, Christman M, Reina B, Bishop F et<br />
al. Is Internet Pornography Causing Sexual Dysfunctions? A Review<br />
with Clinical Reports. Behavioral Sciences. 2016;6(3):17.<br />
22. Pizzol D, Bertoldo A, Foresta C. Adolescents and web porn: a<br />
new era of sexuality. International Journal of Adolescent Medicine<br />
and Health. 2015;0(0).<br />
23. Park B, Wilson G, Berger J, Christman M, Reina B, Bishop F et<br />
al. Is Internet Pornography Causing Sexual Dysfunctions? A Review<br />
with Clinical Reports. Behavioral Sciences. 2016;6(3):17.<br />
24. Doidge N. The Brain That Changes Itself: Stories of Personal<br />
Triumph from the Fontiers of Brain Science. 1st ed. New York:<br />
Penguin Books; 2007.<br />
25. Porto R. Habitudes masturbatoires et dysfonctions sexuelles<br />
masculines. Sexologies. 2016;25(4):160-165.<br />
26. Perry S. Does Viewing Pornography Reduce Marital Quality<br />
Over Time? Evidence from Longitudinal Data. Archives of Sexual<br />
Behavior. 2016;46(2):549-559.<br />
27. Leppink E, Chamberlain S, Redden S, Grant J. Problematic<br />
sexual behavior in young adults: Associations across clinical,<br />
behavioral, and neurocognitive variables. Psychiatry Research.<br />
2016;246:230-235.<br />
28. Yoder V, Virden T, Amin K. Internet Pornography and<br />
Loneliness: An Association?. Sexual Addiction & Compulsivity.<br />
2005;<strong>12</strong>(1):19-44.<br />
29. Boies S, Cooper A, Osborne C. Variations in Internet-Related<br />
Problems and Psychosocial Functioning in Online Sexual Activities:<br />
Implications for Social and Sexual Development of Young Adults.<br />
CyberPsychology & Behavior. 2004;7(2):207-230.<br />
30. Ma C. Relationships between Exposure to Online<br />
Pornography, Psychological Well-Being and Sexual Permissiveness<br />
among Hong Kong Chinese Adolescents: a Three-Wave<br />
Longitudinal Study. Applied Research in Quality of Life. <strong>2018</strong>;.<br />
31. Doornwaard S, van den Eijnden R, Baams L, Vanwesenbeeck<br />
I, ter Bogt T. Lower Psychological Well-Being and Excessive Sexual<br />
Interest Predict Symptoms of Compulsive Use of Sexually Explicit<br />
Internet Material Among Adolescent Boys. Journal of Youth and<br />
Adolescence. 2015;45(1):73-84.<br />
17
Improving interactions between transgender and other<br />
gender-diverse persons and the healthcare system<br />
Review article<br />
Meredith Grey & Imogen Janus<br />
Meredith Grey is a third year medical student at the University of Sydney. She studied<br />
public health in her undergraduate degree, and maintains a strong interest in health<br />
justice.<br />
Imogen Janus is a third year medical student at the University of Sydney who is<br />
passionate about gender-diversity within medicine. She is hopeful for future cultural<br />
change within medicine that will benefit people of all sexes, genders, and sexualities.<br />
“<br />
Abstract<br />
Background: Individuals who do not identify with the normative gender identities experience<br />
differences in access and treatment in the healthcare system as compared with their gender-binary<br />
counterparts, both as patients and professionals. These disparities are hard to quantify due to a<br />
paucity of specific and appropriate research to date.<br />
Aims: To identify and explore the main barriers faced by gender-diverse individuals in accessing<br />
appropriate healthcare, and by gender-diverse healthcare professionals in entering the health<br />
workforce.<br />
Methods: We reviewed the interactions between gender-diverse individuals and healthcare systems<br />
by searching key databases including Google Scholar, EMBASE, and PubMed, as well as grey literature<br />
from selected research bodies and peak community organisations. Search terms included: transgender,<br />
transsexual, gender-diverse, gender dysphoria, health, healthcare, mental health, sex, and gender.<br />
Results: Many large studies looking at gender-diverse healthcare do so under umbrella terms like<br />
LGBTQI, and lack specific information about our target population. Some smaller international studies<br />
and anecdotal reports highlight areas of focus for future research. From the available literature, it<br />
appears that the primary barriers to care are a lack of knowledge about and erasure of the genderdiverse<br />
experience, subsequent discrimination, inadequate and inappropriate healthcare, and a<br />
consequent strained relationship between gender-diverse people and the mainstream healthcare<br />
system.<br />
Conclusions: Gender-diverse people experience barriers to healthcare at the individual, institutional<br />
and societal level due to obvious challenges like discrimination and lack of understanding, and more<br />
insidious issues like erasure, bureaucratic and financial barriers. Assessing the scope of these factors<br />
with robust research and taking pragmatic steps towards increasing visibility, education and societal<br />
support will go a long way to changing the healthcare landscape and the experience of genderdiverse<br />
people within it.<br />
Introduction<br />
Individuals that do not identify with the<br />
normative gender expectations set by society often<br />
suffer significant negative health disparities when<br />
compared with their binary counterparts. These<br />
disparities are often hard to identify and quantify due<br />
to a paucity of evidence specific to these individuals.<br />
This article reviews current interactions between<br />
gender-diverse individuals and healthcare systems<br />
”<br />
with reference to the available literature. The article<br />
explores barriers faced by gender-diverse patients,<br />
as well as gender-diverse healthcare professionals in<br />
forming a part of the health workforce. We conclude<br />
that the primary barrier is a lack of knowledge<br />
about the gender-diverse experience, which leads<br />
to discrimination, inadequate or even inappropriate<br />
healthcare, and a consequent withdrawal from the<br />
mainstream healthcare system. Structural factors<br />
such as the binary description of gender used by<br />
medical systems leads to a lack of visibility of these<br />
18
individuals, both within healthcare organisations<br />
and research. Further, for healthcare professionals,<br />
there are actual or perceived potential professional<br />
ramifications of expressing their gender-identity. We<br />
propose that the identification and understanding<br />
of these barriers will assist healthcare workers and<br />
organisations in Australia to begin to address these<br />
disparities.<br />
Terminology<br />
To accurately and respectfully<br />
interact with issues about gender<br />
and healthcare, it is important to use<br />
terminology that is appropriate and<br />
specific. Here we outline the terminology<br />
most pertinent to this article. Cisgender<br />
refers to people whose gender<br />
identity is the same as the sex they<br />
were assigned at birth. In this paper,<br />
the choice to use the term ‘genderdiverse’<br />
encompasses any and all<br />
gender identities outside the cisgender the<br />
‘male’ and ‘female’. This encompasses<br />
transgender people, who often identify<br />
as ‘male’ or ‘female’, but whose gender<br />
differs from the sex they were assigned<br />
at birth, as well as intersex, gender nonbinary<br />
and gender-queer people whose<br />
gender identity may not fall within the<br />
categorical binary. These definitions are<br />
not absolute nor comprehensive, and we<br />
acknowledge that gender terminology<br />
is an evolving and dynamic field. For<br />
a more comprehensive explanation of<br />
different terms used when regarding<br />
sex and gender, we recommend the<br />
University of Technology, Sydney’s LGBTIQ+ glossary:<br />
Physical Sex, Sexuality, Gender Identity and Gender<br />
Expression.[1]<br />
Gender-diverse patients and the healthcare<br />
system<br />
Understanding the unique needs of Australia’s<br />
gender-diverse community is a major public<br />
health challenge. This is due to the lack of research<br />
specifically aimed at addressing the health needs of<br />
this community, the exclusion of non-binary gender<br />
identities in research and policy, and the conflation<br />
of sex, gender and sexuality in the data collected.<br />
In Australia, there have not yet been any national<br />
population-based data collected regarding gender<br />
identity. Currently the Australian Bureau of Statistics<br />
is reviewing its Sex Standard, which currently codes<br />
only ‘male’ and ‘female’ in the census, but as yet<br />
no new policies have been outlined.[2] Studies that<br />
do look at health outcomes for gender-diverse<br />
people often do so as part of umbrella-terms, such<br />
as LGBTQI, encompassing various gender identities,<br />
sexual orientations and sexual behaviours,[3] which<br />
can fail to identify unique issues affecting these<br />
diverse subgroups. Finally, health priorities and<br />
‘In Australia, there<br />
have not yet been any<br />
national populationbased<br />
data collected<br />
regarding gender<br />
identity. Currently<br />
Australian<br />
Bureau of Statistics<br />
is reviewing its Sex<br />
Standard, which<br />
currently codes only<br />
‘male’ and ‘female’ in<br />
the census, but as yet<br />
no new policies have<br />
been outlined.[2]’<br />
needs can and do differ within sub-groups – for<br />
example, transgender men and transgender women<br />
have different experiences within the healthcare<br />
system and different specific needs as patients, which<br />
can be overlooked when considering the health of<br />
transgender people more broadly.<br />
Recently, however, smaller-scale surveys and data<br />
have been emerging parsing out health and wellbeing<br />
outcomes specifically for gender-diverse people. This<br />
research suggests that health outcomes are poorer<br />
among trans-identifying people<br />
than the wider population, as well<br />
as other groups that are part of<br />
the LGBTQI community. Patientreported<br />
health outcomes such<br />
as in Private Lives 2, a 20<strong>12</strong><br />
health survey of more than<br />
3,000 gay, lesbian, bisexual<br />
and transgender Australians,<br />
demonstrated that transgender<br />
men and women reported lower<br />
levels of general health than both<br />
the national average, and than<br />
cis-gendered gay, lesbian and<br />
bisexual respondents.[4] Specific<br />
disparities faced by genderdiverse<br />
people include reduced<br />
engagement with cervical<br />
cancer screening programs and<br />
increased rates of smoking and<br />
associated diseases.[5,6]<br />
Mental health is a particular<br />
area of disparity, with both<br />
transgender men and women<br />
averaging scores of 23.2 on<br />
the Kessler Psychological Distress Scale, indicating<br />
high psychological stress,[7] with more than half of<br />
gender-diverse people experiencing a diagnosis of<br />
depression in their adult lifetime.[6] Suicidality is of<br />
particular concern, with transgender people <strong>12</strong> times<br />
more likely to contemplate and 11 times more likely<br />
to commit suicide than the general population in<br />
Australia.[7] As well as high rates of depression and<br />
anxiety, transgender individuals also report higher<br />
than average rates of other psychiatric conditions,<br />
with 23.4% of transgender men reporting such<br />
conditions, compared to 3.2% of cis-gendered men.<br />
[4] With this in mind, it is still difficult to confidently<br />
quantify the particular health challenges faced by<br />
gender-diverse populations, as these conclusions<br />
come from small studies and/or studies looking more<br />
broadly at LGBTQI groups.<br />
There are a myriad of factors contributing to<br />
the healthcare disparities experienced by genderdiverse<br />
populations, and these issues range from<br />
interpersonal challenges between patient and<br />
practitioner, to hospital and institutional practices,<br />
policies and structures and finally political and<br />
societal context. It is important to note, as found<br />
in research conducted by the Australian Research<br />
19
Centre in Sex, Health and Society between 2007 and<br />
2014, that the poorer health outcomes experienced<br />
by gender-diverse people in Australia are due to<br />
these contextual factors like stigma and access, and<br />
are not due to anything inherent to this identity.[6]<br />
In the 2011 National Transgender Discrimination<br />
Survey of more than 6000 transgender people in<br />
the United States, large numbers of respondents<br />
reported experiencing violence, harassment, and<br />
discrimination when seeking medical care, with 23%<br />
being denied care altogether.[8] These negative<br />
interactions reportedly lead to individuals postponing<br />
or avoiding medical care.[8]<br />
Healthcare providers are also lacking in both<br />
understanding the transgender experience and<br />
delivering quality care to gender-diverse people<br />
due to a lack of basic knowledge in these areas. This<br />
begins with a failure to understand the continuums<br />
of and differences between sex, gender, and<br />
sexuality, and the tendency to conflate and confuse<br />
these terms. It also relates to the lack of education<br />
surrounding the specific healthcare needs of genderdiverse<br />
people, including gender-affirming therapies<br />
and their side effects, sexual health, and fertility.<br />
The National Transgender Discrimination Survey<br />
found that half of respondents reported having to<br />
teach their healthcare providers about transgender<br />
health.[8] While some specialties such as General<br />
Practice have higher reported rates of positive<br />
clinical experiences for gender-diverse people,<br />
stigma and misunderstanding is present even<br />
among those professions that are most likely to be<br />
involved in providing care to gender-diverse people,<br />
including psychiatrists, gynaecologists and paediatric<br />
endocrinologists.[9–11]<br />
There are also socio-political structures that<br />
create barriers to healthcare access at an institutional<br />
level.[6] Many of the healthcare disparities faced by<br />
gender-diverse people in this setting relate to their<br />
lack of visibility. Simply, most healthcare organisations<br />
collect patient data about sex or gender - often used<br />
interchangeably - as a binary of ‘male’ or ‘female’.<br />
This method excludes those who do not identify<br />
within the binary, while simultaneously rendering<br />
transgender experience invisible, as it fails to capture<br />
the difference between an individual’s sex-at-birth<br />
and current gender identity. The purported aim of<br />
collecting this information is two-fold: to identify<br />
the sex-specific healthcare needs of a person, for<br />
example, the likelihood of pregnancy, and to provide<br />
gender-appropriate interactions, for example, the<br />
appropriate use of pronouns. However, the method<br />
of presenting patients as either ‘male’ or ‘female’ fails<br />
to serve either of these aims in relation to genderdiverse<br />
people.[<strong>12</strong>] In this binary system, transgender,<br />
intersex and other gender-diverse people are<br />
effectively invisible, a process termed ‘erasure’.[13]<br />
The erasure that exists in health data collection<br />
is mirrored in many bureaucratic contexts, which<br />
themselves contribute to the substantial barrier to<br />
care that gender-diverse people face. For example, a<br />
large survey in the United States in 2015 found that<br />
only 11% of gender-diverse respondents had their<br />
accurate name and gender on all their official identity<br />
documents, with reasons for not changing their<br />
20
legal name including financial capacity and lack of<br />
procedural knowledge.[14] In Australia, most states<br />
and territories have significant barriers to correcting<br />
gender markers on official documentation such as<br />
being unmarried or having had surgery to alter their<br />
reproductive organs.[6] If individuals are provided<br />
avenues to change or correct their gender marker<br />
within their medical record, these processes can be<br />
insensitive, often requiring intrusive forms of ‘proof’,<br />
and imposing significant administrative burden and<br />
psychological distress on people seeking to do so.[6]<br />
It is important to note that the inconsistent and<br />
inappropriate use of gender markers extends beyond<br />
clinical practice. This erasure exists across all levels<br />
of data-gathering and makes collecting and locating<br />
data about the health and wellbeing of genderdiverse<br />
people difficult, which in turn makes it hard to<br />
identify areas of need and action. Both demographic<br />
information and data regarding cause and effects of<br />
outcomes are necessary to create an evidence-based<br />
approach to the healthcare of gender-diverse people.<br />
Indeed, standardised tools have been created for<br />
use at various levels from population to individual<br />
clinic,[15] but large-scale implementation of these<br />
standards are still required to fill gaps that exist in<br />
our knowledge of both specific health challenges for<br />
gender-diverse people and appropriate strategies to<br />
address them. [15]<br />
If and when basic issues of visibility can be<br />
overcome, gender-diverse people face real pragmatic<br />
barriers to care in the form of governmental<br />
regulations and priorities. For example, the<br />
financial burdens placed on transgender people<br />
seeking gender-affirming therapies not currently<br />
funded by public or private health insurance. In<br />
recent years, there have been proposed changes<br />
to governmental policy in an attempt to address<br />
systemic barriers that gender-diverse people face in<br />
the healthcare system. Access to many Medicare and<br />
Pharmaceutical Benefits Scheme (PBS)-subsidised<br />
items are dependent on patients’ Medicare gender<br />
classification (either ‘male’ or ‘female’), making access<br />
to certain procedures and medications difficult for<br />
gender-diverse people. 6,000 such procedures and<br />
treatments were proposed to be modified to remove<br />
gender-dependent classifications, for example,<br />
making cervical cancer screening available to anyone<br />
with a cervix, as opposed to people whose marker<br />
is ‘female’.[6] As of 2014, only 15 of the particular<br />
Medical Benefits Scheme billing codes had been<br />
changed.[6] Furthermore, some gender-affirming<br />
management options are still classified as cosmetic<br />
procedures and as such are not covered by Medicare.<br />
These policy-related issues contribute both to the<br />
significant barriers gender-diverse people face<br />
generally in accessing care both for their well being,<br />
and those faced by transgender people seeking<br />
specific transition-related care.[6]<br />
The Australian Medical Association (AMA)<br />
recognises transgender, intersex and genderdiverse<br />
people as a priority population in sexual and<br />
reproductive health.[16] Their 2014 policy document<br />
on sexual and reproductive health stresses the<br />
importance of reducing stigma in the healthcare<br />
setting, encouraging access to gender affirming<br />
procedures and medications, and improving data<br />
collection and research to identify gaps and improve<br />
the experience that gender-diverse people have with<br />
our healthcare system.[16]<br />
Similarly, the Australian Medical Student<br />
Association (AMSA) released a policy statement in<br />
2016, echoing the sentiment of the AMA document,<br />
as well as outlining specific recommendations for<br />
government bodies, medical schools and student<br />
societies to promote LGBTQI health and wellbeing.<br />
[17] As well as presenting recommendations for the<br />
provision of more competent healthcare to genderdiverse<br />
patients, AMSA’s policy guidelines address<br />
changing the professional culture and the roles<br />
that medical schools and student societies play.<br />
The document calls on medical schools to promote<br />
visibility of LGBTQI health with integrated, accurate<br />
and destigmatised curricula, as well as inviting the<br />
participation of LGBTQI health care providers and<br />
community members to be involved in teaching and<br />
curriculum building. It also highlights the role of<br />
student societies in protecting and promoting the<br />
interests of LGBTQI students as well as raising the<br />
quality of teaching around gender and sexuality.[17]<br />
Gender-diverse healthcare professionals<br />
While only a small amount of research is available<br />
regarding gender-diverse patients, there is an even<br />
greater paucity of data regarding gender-diverse<br />
healthcare providers. However, with personal<br />
accounts of gender-diverse people who have chosen<br />
to write about their experience as medical students<br />
and doctors, as well as some small studies and reports<br />
of gender-diverse groups in the health workforce,<br />
we can begin to build a picture of gender-diversity<br />
among healthcare professionals.<br />
Barriers for gender-diverse people in the<br />
healthcare workforce can emerge early, as evidenced<br />
by recent studies looking at how gender and<br />
sexuality is addressed and taught in medical schools.<br />
A 2015 survey conducted at Stanford Medical<br />
School investigated the experience of LGBT-related<br />
education by both LGBT and non-LGBT medical<br />
students. One quarter of LGBT students and 8% of<br />
non-LGBT students found the quality of their teaching<br />
surrounding LGBT issues to be ‘very poor’, and the<br />
discrepancy between these numbers highlights that<br />
the LGBT students did not feel their experience was<br />
represented appropriately.[18] Jai NicAllen, a British<br />
medical student wrote of their experience as a transperson<br />
in medical school in an article for the Student<br />
British Medical Journal, noting challenges including<br />
factually inaccurate information about gender and<br />
health, and a generalised lack of knowledge among<br />
peers and teachers.[19] Furthermore, while the<br />
majority of medical schools provided at least 3 hours<br />
21
of teaching on sexuality broadly, it is difficult to know<br />
what and how gender is included in these curricula,<br />
and many reported little to no information about<br />
gender-diversity in their teaching.[20]<br />
The potential result of the educational failures<br />
suggested by these studies is a medical workforce<br />
that lacks the confidence and capacity for caring<br />
appropriately for gender-diverse patients, but it also<br />
fosters an unwelcoming environment for genderdiverse<br />
medical students and professionals. With<br />
fear of discrimination from medical schools and<br />
residency programs being the two most common<br />
reasons among medical students for choosing not to<br />
disclose gender-diverse gender identity or sexuality,<br />
the failures of medical schools surrounding genderdiversity<br />
teaching carry on into the workplace with<br />
ongoing stigma and professional consequences<br />
for gender-diverse doctors.[18] In the absence of<br />
formalised information and support for genderdiverse<br />
students and young doctors, informal peer<br />
spaces like student forums and chat rooms provide<br />
some of the only reliable and confidential aid in<br />
navigating educational and career-related decisions.<br />
Most LGBT<br />
physicians continue<br />
to work in settings<br />
where they are<br />
invisible”<br />
The data available about gender-diverse doctors<br />
and other healthcare providers paint a similar picture<br />
of deficits and discrimination. A 2011 report put it<br />
powerfully: “most LGBT physicians continue to work<br />
in settings where they are invisible”.[20] Robust<br />
policies surrounding gender-related issues in the<br />
workplace including harassment and reporting,<br />
pronoun use, dress codes, appropriate facilities,<br />
and general employee education surrounding<br />
gender identity are becoming more common and<br />
exist in various guidelines.[21–23] However, there is<br />
little adoption or creation of such guidelines in the<br />
healthcare employment setting, and many genderdiverse<br />
physicians are not even aware of their<br />
workplace policies regarding gender and sexuality<br />
both for patients and employees, with 28% of<br />
respondents in the 2011 study noting they did not<br />
know whether their employer’s non-discrimination<br />
policy included gender identity at all.[20] Rates of<br />
harassment and ostracisation of LGBT physicians<br />
based on gender identity and sexuality have shown<br />
improvement over the last 20 years, but still sit at<br />
15% and 20% respectively in one reported study.<br />
[20] These discriminatory experiences can be at the<br />
hands of peers and bosses, but also patients, with<br />
a 2007 national study in the United States reporting<br />
that 30% of responders would change healthcare<br />
providers upon learning theirs identified as LGBT.<br />
[24] Finally, when considering reporting instances of<br />
discrimination, gender-diverse healthcare workers<br />
also have to consider how their identity and the<br />
perception of it by their superiors could affect<br />
their careers, for example regarding exclusion from<br />
promotions or other opportunities.[20]<br />
Conclusions<br />
The lack of large scale and robust data<br />
representing experiences of gender-diverse people<br />
in the Australian health system speaks to their lack<br />
of visibility, acceptance and representation within the<br />
healthcare system both as patients and professionals.<br />
Furthermore, the data and perspectives that are<br />
available highlight that the erasure and inappropriate<br />
treatment of gender-diverse people in healthcare is<br />
not uncommon, nor is it uncommon knowledge.<br />
The challenges that affect both the health outcomes<br />
of gender-diverse people and their experience in<br />
the healthcare industry are due to barriers that exist<br />
at several levels. Individual factors in patient-carer<br />
interactions including prejudice and lack of awareness<br />
or confidence negatively influence gender-diverse<br />
people’s access to and engagement with healthcare<br />
professionals. Institutional factors such as the binary<br />
description of gender used by medical systems leads<br />
to a lack of visibility of gender-diverse individuals,<br />
both within healthcare organisations and research.<br />
Policy and structural considerations including<br />
governmental focus, financial subsidies and public<br />
policy define the context in which gender-diverse<br />
people exist and interact with the healthcare system.<br />
Finally, for healthcare professionals, there are real<br />
workplace ramifications of expressing their genderidentity,<br />
as well as associated fear or anxiety of<br />
doing so. We propose that the identification and<br />
understanding of these barriers will assist healthcare<br />
workers and organisations in Australia to begin to<br />
address these disparities.<br />
Despite the perspectives of our large professional<br />
bodies, as well as the growing body of data,<br />
anecdotal experiences of gender-diverse people<br />
and the availability of guidelines, templates and<br />
recommendations both for gender-diverse patient<br />
care and employee relations, healthcare institutions<br />
in Australia are slow to change. In this case, the<br />
resources are available, and many of the necessary<br />
steps outlined in the relevant guidelines are<br />
simple, inexpensive and quick to implement on an<br />
institutional level. Reevaluating policy, practice and<br />
attitudes relating to gender-diverse patients and<br />
employees, and creating institution and industrywide<br />
practical standards emphasising visibility,<br />
education and appropriate structural supports for<br />
gender-diverse people is possible and overdue.<br />
Abbreviations<br />
LGBTQI: Different studies referred to in this<br />
paper use different umbrella or categorical terms<br />
such as LGBT, LGBTQI and GLBT. With this in mind,<br />
inconsistencies in the use of these terms may exist<br />
22
in this review and are reflective of the terms used<br />
in the specific studies or papers referenced.<br />
Acknowledgements<br />
This work is part of a larger research project<br />
done on behalf of Level Medicine, an organisation<br />
working towards gender equity in medicine.<br />
If you have feedback about the contents of this<br />
article or think that there are any particular<br />
actions Level Medicine can take to improve<br />
the experience of transgender and other genderdiverse<br />
people within the healthcare system,<br />
please contact the corresponding author.<br />
Photo credits<br />
Daniel Watson, accessed from https://unsplash.<br />
com/photos/IEtUye-b28A<br />
Conflicts of interest<br />
The authors do not work for, consult, own<br />
shares in or receive funding from any company<br />
or organisation that would benefit from this<br />
article, beyond an affiliation with Level Medicine.<br />
Correspondence<br />
mgre75<strong>12</strong>@uni.sydney.edu.a<br />
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The public perception of major depressive disorder in<br />
South Asia: a literature review<br />
Review article<br />
Marisse Sonido<br />
Marisse Sonido is currently a 4th year medical student at the University of<br />
New South Wales. She is both an aspiring doctor and writer and has recently<br />
discovered, much to her excitement, that the two are not mutually exclusive.<br />
“<br />
Abstract<br />
Aims: To understand: the perception of depression as an illness in South Asia and the language used<br />
to describe it, its perceived aetiology, how individuals with depression are perceived by the community<br />
and the beliefs in the community surrounding the treatment of depression.<br />
Methods: Articles were found through a database search of MedLine, PSYCINFO, and GoogleScholar.<br />
They were included if they discussed depression within the context of a South Asian culture.<br />
Results: Depression is widely understood in South Asia as a disease with primarily somatic presentations<br />
stemming from stresses associated with difficult socioeconomic circumstances. Those with depression<br />
are often stigmatised but they are generally not excluded from the community. Alongside medical<br />
intervention, assistance from family and the community are the most accepted methods of addressing<br />
depression.<br />
Conclusions: South Asian perceptions of depression accord with a psychosocial model of illness.<br />
Incorporating these perceptions is essential to the success of interventions and educational programs<br />
hoping to resonate with a general population and improve communication with health professionals.<br />
Introduction<br />
Depression, suffered by more than 300 million<br />
people worldwide, represents the single greatest<br />
contributor to global non-fatal health loss.[1, 2, 3] Its<br />
impacts are not limited to the Western world. While<br />
developed countries draw much of the research<br />
focus, the South Asian prevalence of depression<br />
was calculated at 26.3% based on primary care<br />
presentations.[1] In India in 2004 it accounted for<br />
a greater number of disability adjusted life years<br />
per 100,000 people than both cancer and diabetes<br />
mellitus combined.[1] Depression is particularly<br />
under-recognised and undertreated in rural areas.[4]<br />
The presentations, sequelae and understandings<br />
of depression are known to depend on culture, a<br />
relationship maintained in the South Asian context.<br />
[5, 6, 7, 8] Existing research highlights significant<br />
differences between developed and developing<br />
world perspectives on the disease—the extent<br />
to which depression is seen as somatic, the role<br />
of socioeconomic factors in its aetiology and<br />
community responsibilities in addressing it.[4] The<br />
strict biomedical conception of depression favoured<br />
by some health professionals may translate poorly<br />
across cultures and pose obstacles to improving<br />
recognition, treatment and education.[9]<br />
This paper aims to discuss general perceptions<br />
of depression in developing countries in South Asia.<br />
It will identify community views on: (1) depression<br />
as an illness, including the way it is described and<br />
presents; (2) its aetiology; (3) opinions about<br />
individuals with depression; and (4) beliefs about<br />
treatment. In synthesising the trends and repeating<br />
themes revealed by research, it hopes to provide a<br />
foundation for tailoring clinical and public health<br />
interventions to a South Asian cultural context.<br />
Methods<br />
”<br />
Articles were found through a database search<br />
of MedLine, PSYCINFO, and GoogleScholar using<br />
the following keywords and MESH terms: Mental<br />
Disorders OR Depression; Developing Countries OR<br />
24
Asia OR Afghanistan OR India OR Sri Lanka OR Nepal<br />
OR Bhutan OR Maldives OR Pakistan; and Stigma,<br />
Public Perception, Understanding, OR Health Literacy.<br />
Studies were excluded if they were not published<br />
English language articles relating to depression in<br />
South Asian cultures.<br />
Results<br />
Relevant studies were found about samples in<br />
India (n = 3), Pakistan (n = 1), Afghanistan (n = 1),<br />
Bangladesh (n = 1) and Sri Lanka (n = 1). The Afghan<br />
sample reflected a migrant Afghan population. No<br />
depression-specific articles were found about the<br />
Maldives, Bhutan and Nepal.<br />
Understanding of depression as a disease<br />
Participants generally professed a poor medical<br />
understanding of depression and other mental<br />
illnesses. Many in the Liu et al. study (42.77%) could<br />
not answer what the word ‘depression’ meant to<br />
them.[4] In the Indian state of Maharashtra, 87.5%<br />
of community members did not acknowledge<br />
depression as a real medical illness.[10] However,<br />
participant groups frequently employed locally<br />
appropriate terminology when presented with a<br />
depression case study or vignette. Bangladeshi<br />
respondents referred to chinta rog or “worry illness”.<br />
[5] The Dari language speaks of asfurgdadi, the low<br />
mood and grief associated with hardships.[11] Using<br />
tailored vocabulary greatly improved communication<br />
between researchers and participants.[5]<br />
Both participants with depression and communities<br />
in general stressed the physical manifestations of the<br />
disease.[4, 5, 6, 9] The most commonly identified<br />
somatic symptoms associated with depression<br />
included fatigue, pain, numbness, sleeplessness,<br />
headache, breathlessness, and shaking.[5, 6, 9, 11]<br />
While several psychological symptoms were also<br />
listed,[5, 11] the physical aspects of the disease<br />
dominated and were often the main reasons to seek<br />
help.[6]<br />
Aetiology of depression<br />
An overwhelming majority of study participants<br />
described depression through a psychosocial<br />
understanding of its origins, emphasising the<br />
suffering individual’s social context. In rural Indian<br />
villages, depression is seen as an accumulation and<br />
escalation of grief or stress.[4] Many studies identified<br />
poverty and unemployment as major contributors to<br />
these pressures.[5, 6, 9] In Bangladesh it is believed<br />
that all tension rogs or “anxiety illnesses” are due<br />
to obhab, a (typically material) need of some kind<br />
caused by poverty.[5] Culturally specific financial<br />
stressors included an inability to provide dowry<br />
and education for all of one’s daughters.[5] Other<br />
stressors ranged from female reproductive problems<br />
and domestic violence to social inequality, injustice,<br />
and trauma.[4, 6, 9, 11] Refugees interviewed by<br />
Alemi et al. described language difficulties, family<br />
separations and cultural clashes.[11]<br />
A number of participants attributed depression to<br />
religious, supernatural or spiritual factors. A vignette<br />
about a woman with depression in Liu et al.’s<br />
study prompted participant theories about divine<br />
punishment and black magic.[4] Many raised the<br />
possibility of spiritual possession.[4]<br />
The Liu et al. study was an outlier in terms of<br />
biological explanations for aetiology— 54% of<br />
respondents linked depression to a disease of the<br />
brain and 33.8% believed it was inheritable.[4] The<br />
presentation of these options in a questionnaire,<br />
as opposed to the open-ended interviews of other<br />
studies, may have contributed to this divergence. But<br />
some of the external causative factors identified by<br />
participants, like “problems in the environment”[6]<br />
and polluted air,[4] also hint at a biological<br />
understanding of depression’s causes.<br />
Perception of individuals with depression<br />
Expressions of stigma were common. In two<br />
of the Indian studies the majority of individuals<br />
believed depression is a sign of weakness.[4, 10] In<br />
the Kermode et al. study,[10] 40% of community<br />
members concurred that people with depression<br />
are dangerous, 52.1% said they are erratic and<br />
42.5% believed they should be avoided. Similarly, a<br />
large minority of respondents in the Liu et al. study<br />
described those with depression as unpredictable<br />
(43.8%), hard to talk with (40.5%), and a cause of<br />
familial shame (45.1%).[4]<br />
Despite this, most individuals expressed a<br />
willingness to remain the neighbours, friends and<br />
co-workers of someone with depression.[4, 10]<br />
These opinions were more likely in respondents who<br />
regarded depression as a “sign of weakness” instead<br />
of a genetic or biological disease. However, only<br />
60.8% of participants were willing to accept someone<br />
with depression marrying into their family.[10]<br />
Bangladeshi respondents echoed these doubts about<br />
the marriage prospects of people with depression.[5]<br />
Understandings of treatment<br />
Most participants across the studies thought<br />
depression would be difficult—if not impossible—to<br />
remedy without assistance.[4, 10, 11]<br />
Pharmaceutical treatments were often poorly<br />
understood and warily regarded. Medication was<br />
restricted to treating the physical symptoms of<br />
depression.[9] Some participants were concerned<br />
about the addictive potential of using drugs to treat<br />
depression.[4] In Bangladesh, tablets were the option<br />
of last resort, partly due to cost.[5] Bangladeshi<br />
respondents instead prioritised poverty alleviation,<br />
good health and positive family relations.[5]<br />
Opinions of medical practitioners were generally<br />
positive. The patients in the Naeem et al. study<br />
professed a strong faith in doctors despite minimal<br />
25
awareness of their role in depression management<br />
and limited familiarity with non-pharmacological<br />
treatments like psychotherapy.[6] Sri Lankan<br />
undergraduate students who saw depression as a<br />
mental illness had confidence in medical experts[<strong>12</strong>]<br />
and refugees in Afghanistan also expressed faith in<br />
psychiatrists.[11]<br />
Opinions about traditional and religious healing<br />
modalities were mixed across the studies. In India,<br />
some respondents reported using herbal medicine<br />
to treat depression’s somatic symptoms,[9] and<br />
participants from Afghanistan sometimes consulted<br />
a tabib or herbal specialist.[11] A minority in the<br />
Indian, Bangladeshi, and Afghan samples identified<br />
religious practices, mantras and amulets as possible<br />
remedies.[5, 9, 11] Conversely, in another study,<br />
63% of participants doubted traditional healers<br />
could successfully remedy depression, with more<br />
enthusiasm for their effectiveness only in conjunction<br />
with medical treatment.[4] None of the participants<br />
in the Pakistan study had visited a traditional healer,<br />
though one participant did recite passages from<br />
the Quran and perform the practice of do dum (or<br />
blowing air) on themselves as a form of self-help.[6]<br />
Several studies highlighted familial or social<br />
support as a particularly popular treatment option.[4,<br />
5, 9] Bangladeshi respondents typically approached<br />
family members and close relatives before seeking<br />
help from other sources. Many of these individuals<br />
believed a community-based program would be the<br />
ideal way to address depression.[5] Other suggested<br />
treatments included involvement in communal<br />
activities,[5, 9] internal dialogue[9]<br />
and lifestyle changes such as eating<br />
right and exercising.[11] In Alemi et al.,<br />
cultural activities, such as listening to<br />
Afghan music and visiting Afghanistan,<br />
were also named.[11]<br />
Discussion<br />
The reviewed literature suggests<br />
depression in South Asia is widely<br />
understood as a stress-related<br />
disease that emerges out of difficult<br />
socioeconomic circumstances and has<br />
primarily somatic manifestations. While<br />
those with depression are still subject to<br />
stigma, communal exclusion is rare.[4,<br />
10] Familial and community assistance<br />
are the most accepted treatments for depression with<br />
medical intervention reserved for physical symptoms.<br />
[4, 5]<br />
South Asian respondents overwhelmingly<br />
favoured a psychosocial model of depression’s<br />
aetiology with minimal emphasis on biology.<br />
Empathy and understanding seemed highest when<br />
causal explanations of depression were linked to<br />
relatable hardships. Education campaigns and anti-<br />
stigma efforts may have more success if framed<br />
through this understanding of the disease compared<br />
to approaches rooted in biomedicine. In Kermode et<br />
al., individuals who related depression to a personal<br />
flaw (“weakness”) or extrinsic factors (e.g., family<br />
and financial problems) were less likely to socially<br />
distance themselves from people with depression<br />
compared to those who believed in a biological<br />
cause.[10] Biology may be seen to imply a lack of<br />
agency and the possibility of hereditary transmission,<br />
both of which negatively impact marriage prospects.<br />
This aetiological understanding of depression<br />
affects the acceptance of pharmacological<br />
interventions. While Indian respondents used<br />
pharmacological treatments for somatic symptoms,<br />
and drugs are seen as a valid last resort in<br />
Bangladesh,[5] the expense and arcane mechanisms<br />
of action of antidepressants may compromise<br />
adherence when they are prescribed. Nonpharmacological<br />
methods might be more acceptable<br />
despite remaining mostly unheard of in more rural<br />
areas. A study on university students in Pakistan, for<br />
example, found that cognitive behavioural therapy<br />
could be successful in that population provided<br />
interventions are tailored to South Asian cultural and<br />
religious values.[13]<br />
As depression is commonly attributed to external<br />
socioeconomic factors, programs addressing these<br />
wider social issues may reduce its prevalence. Studies<br />
investigating poverty alleviation as an intervention<br />
for depression have reported conflicting results in<br />
Uganda and Mexico.[14, 15] The evidence suggests<br />
depression interventions<br />
demand a multi-faceted<br />
approach.<br />
‘... depression<br />
in South Asia is<br />
widely understood<br />
as a stress-related<br />
disease that emerges<br />
out of difficult<br />
socioeconomic<br />
circumstances and<br />
has primarily somatic<br />
manifestations.’<br />
The importance of family<br />
and the community support<br />
for individuals with depression<br />
was a motif across the reviewed<br />
studies. South Asian countries<br />
are characterised by collectivistic<br />
cultures emphasising close<br />
family ties.[16] While family and<br />
the community participation in<br />
interventions can be extremely<br />
beneficial, the isolation and<br />
interpersonal conflict associated<br />
with stigma can be especially<br />
damaging. Communitybased<br />
interventions were the ideal approach for<br />
participants in the Selim et al. study.[5] Education<br />
campaigns targeting the family and communities<br />
around individuals with depression may be fruitful.<br />
Limitations<br />
Due to the limited body of research on this topic as<br />
it relates to this region, not every South Asian country<br />
could be represented in this review. The included<br />
studies cannot be interpreted as reflecting universally<br />
26
held beliefs within their respective countries. The<br />
review also only included English-language studies,<br />
narrowing its scope further and perhaps excluding<br />
significant contributions from local research. It is<br />
possible participants were reluctant to openly share<br />
their traditional and religious beliefs with medical<br />
professionals or as part of a scientific study, resulting<br />
in their underrepresentation.[6]<br />
Conclusion<br />
This review aimed to present a general overview<br />
of how depression is perceived in the developing<br />
countries of South Asia. Considering these<br />
synthesised findings may help shape future public<br />
health efforts seeking greater success in improving<br />
education about depression and its treatment and<br />
prevention—in South Asia, and potentially in other<br />
developing countries where depression is similarly<br />
understood.<br />
study in Sri Lanka. BMC Psychiatry. 2015;15(1):269.<br />
13. Naeem F, Gobbi M, Ayub M, Kingdon D. University<br />
students’ views about compatibility of cognitive behaviour therapy<br />
(CBT) with their personal, social and religious values (a study from<br />
Pakistan). Ment Health Relig Cult. 2009;<strong>12</strong>(8):847–55.<br />
14. Ozer EJ, Fernald LCH, Weber A, Flynn EP, VanderWeele TJ.<br />
Does alleviating poverty affect mothers’ depressive symptoms?<br />
A quasi-experimental investigation of Mexico’s Oportunidades<br />
programme. Int J Epidemiol. 2011;40(6):1565–76.<br />
15. Green EP, Blattman C, Jamison J, Annan J. Does poverty<br />
alleviation decrease depression symptoms in post-conflict<br />
settings? A cluster-randomized trial of microenterprise assistance<br />
in Northern Uganda. Glob Ment Health. 2016;3:e7.<br />
16. Chadda RK, Deb KS. Indian family systems, collectivistic<br />
society and psychotherapy. Indian J Psychiatry. 2013;55(Suppl<br />
2):S299–S309.<br />
Acknowledgments<br />
None<br />
Conflicts of Interest<br />
None declared<br />
Correspondence<br />
marisse.sonido@gmail.com<br />
References<br />
1. Reddy R. Depression: the disorder and the burden. Indian J<br />
Psychol Med. 2010;32(1):1–2.<br />
2. World Health Organisation. Depression: World Health<br />
Organisation; <strong>2018</strong> [cited <strong>2018</strong> Aug 16]. Available from: http://<br />
www.who.int/news-room/fact-sheets/detail/depression<br />
3. World Health Organisation. Depression and other common<br />
mental disorders: global health estimates [Internet]. Geneva:<br />
World Health Organisation; 2017 [cited <strong>2018</strong> Aug 16]. Available<br />
from: http://apps.who.int/iris/bitstream/handle/10665/254610/<br />
WHO-MSD-MER-2017.2-eng.pdf?sequence=1<br />
4. Liu MC, Tirth S, Appasani R, Shah S, Katz CL. Knowledge and<br />
attitudes toward depression among community members in rural<br />
Gujarat, India. J Nerv Ment Dis. 2014;202(11):813–21.<br />
5. Selim N. Cultural dimensions of depression in Bangladesh:<br />
a qualitative study in two villages of Matlab. J Health, Popul Nutr.<br />
2010;28(1):95–106.<br />
6. Naeem F, Ayub M, Kingdon D, Gobbi M. Views of depressed<br />
patients in Pakistan concerning their illness, its causes, and<br />
treatments. Qual Health Res. 20<strong>12</strong>;22(8):1083–93.<br />
7. Kleinman A. Anthropology and psychiatry: the role of<br />
culture in cross-cultural research on illness. Br J Psychiatry.<br />
1987;151(4):447–54.<br />
8. McClelland A, Khanam S, Furnham A. Cultural and age<br />
differences in beliefs about depression: British Bangladeshis vs.<br />
British Whites. Ment Health Relig Cult. 2014;17(3):225–38.<br />
9. Pereira B, Andrew G, Pednekar S, Pai R, Pelto P, Patel V.<br />
The explanatory models of depression in low income countries:<br />
listening to women in India. J Affect Disord. 2007;102(1):209–18.<br />
10. Kermode M, Bowen K, Arole S, Pathare S, Jorm AF. Attitudes<br />
to people with mental disorders: a mental health literacy survey<br />
in a rural area of Maharashtra, India. Soc Psychiatry Psychiatr<br />
Epidemiol. 2009;44(<strong>12</strong>):1087–96.<br />
11. Alemi Q, Weller SC, Montgomery S, James S. Afghan refugee<br />
explanatory models of depression: exploring core cultural beliefs<br />
and gender variations. Med Anthropol Q. 2017;31(2):177–97.<br />
<strong>12</strong>. Amarasuriya SD, Jorm AF, Reavley NJ. Quantifying and<br />
predicting depression literacy of undergraduates: a cross sectional<br />
27
Guidelines for low birth weight: a literature review<br />
comparing national guidelines in Lao PDR with<br />
WHO guidelines<br />
Review article<br />
Line M Pederson<br />
Line M Pederson is an intern with the UN Refugee Agency in Copenhagen,<br />
and soon to be working as a research assistant for the Danish Statens Serum<br />
Institut in Guinea-Bissau. Her key interest and priority is to contribute to<br />
building initiatives that ensure cultural and local appropriateness in health<br />
development.<br />
“<br />
Abstract<br />
Background: In Lao PDR (LPDR), the prevalence of low birth weight (LBW) is as high as 15%. Maternal<br />
nutrition is one of the most crucial interventions in reducing the burden of LBW and its consequences<br />
including perinatal and neonatal mortality, childhood stunting and increased risk of NCDs in<br />
adulthood. Guidelines for LBW can be an important tool in prevention and care for LBW infants when<br />
adapted to local contexts.<br />
Objectives: To compare LPDRs and WHOs availability of guidelines for LBW, covering the period from<br />
conception until 6 months postpartum, and to identify barriers for utilisation. This review also aims to<br />
determine the appropriateness of these guidelines for reducing the LBW burden and consequences.<br />
Methods: This literature review was conducted in three steps: identification of global and local risk<br />
factors for LBW; retrieval and comparison of guidelines from WHO and Ministry of Health in LPDR<br />
involving key informants from WHO regional and WHO LPDR office; and searching for barriers and<br />
facilitators for implementation of guidelines. Databases (Pubmed, Proquest and Cochrane Library)<br />
were searched using a combination of key terms: low birth weight, guidelines, Lao PDR, risk factors,<br />
prevention and barriers.<br />
Results: Guidelines were available and accessible by WHO and WHO LPDR office. Based on current<br />
literature, various infrastructural, cultural and financial factors contributes to guidelines often not<br />
being implemented nor accepted among health workers and mothers. Discrepancies between WHO<br />
and local guidelines may have contributed to this, including the current non-aligned cut-off for<br />
referral of LBW infants.<br />
Conclusion: Despite guidelines being available, they were not always applied in LPDR. Inclusion of<br />
vulnerable women in LPDR guidelines were inappropriate for reducing LBW and the risk of adverse<br />
outcomes, but can be strengthened with the launch of guidelines for adolescent reproductive health.<br />
Background<br />
This study was prompted by the persisting<br />
high prevalence of low birth weight (LBW) in Lao<br />
PDR (LPDR), which reached 15% in 20<strong>12</strong>.[1] LBW<br />
is defined as an infant weighing less than 2500g.<br />
It is a leading cause of perinatal (22 weeks of<br />
gestation to 7 days postpartum) and neonatal<br />
(0-28 days) deaths globally.[2] It contributes<br />
to 40-60% of newborn mortality.[2] LBW is<br />
the most important criteria for determining<br />
both immediate and long-term outcomes of<br />
”<br />
neonates and infants. Such outcomes include<br />
chance of survival, healthy growth and freedom<br />
from morbidities including infectious and<br />
cardiovascular diseases and type 2 diabetes.[3-5]<br />
Maternal nutrition has a major impact on LBW<br />
and associated infant morbidity and mortality.<br />
[6-8] Nutritional factors implicate biological<br />
processes, which subsequently affect the foetal<br />
and maternal physiology.[9, 10] The most<br />
important maternal risk factors[11] increasing<br />
LBW risk are; undernutrition and low BMI at<br />
28
In Lao PDR (LPDR), the prevalence of low birth weight (LBW) is as high<br />
as 15%. Maternal nutrition is one of the most crucial interventions in reducing<br />
the burden of LBW and its consequences including perinatal and neonatal<br />
mortality, childhood stunting and increased risk of NCDs in adulthood.<br />
conception[8, 9, <strong>12</strong>-15]; short stature[15, 16];<br />
suboptimal gestational weight gain[11, 15, 17],<br />
deficient intake of micronutrients (iron[18, 19]<br />
and iodine[20]), maternal age (age35[27, 28]) and certain cultural food habits<br />
and behaviours.[29-32]<br />
Maternal and paediatric nutrition researchers<br />
have found that adequate maternal pre-partum<br />
health status, immediate care of the LBW infant<br />
and exclusive breastfeeding (EBF) for 6 months<br />
comprise a set of crucial activities for reducing<br />
the burden of LBW.[33] Guidelines are important<br />
as they act as a tool for quality assurance. This<br />
seeks to improve the quality of care provided by<br />
informed healthcare workers.[34] Evidence-based<br />
and appropriate guidelines have the potential to<br />
promote beneficial interventions and discourage<br />
ineffective practice.[35] However, guidelines<br />
function in the interplay between structural<br />
factors and processes including economic, social<br />
and political environments. This may affect a<br />
guidelines’ desired effect.<br />
Methods<br />
A Quick Scoping Review was performed<br />
to evaluate existing knowledge of LBW. This<br />
involved a rapid review of literature on LBW<br />
risk factors. Guidelines were obtained from the<br />
WHO’s website, online and through formal email<br />
correspondence with the WHO LPDR country<br />
office and WHO Western Pacific Regional office<br />
to ensure the newest updated guidelines were<br />
included.<br />
An extensive literature search was then<br />
conducted to identify barriers for proper<br />
implementation of LBW guidelines in LPDR.<br />
Databases (Pubmed, ProQuest, Cochrane Library,<br />
Google Scholar, WHO and UNICEF) were searched<br />
using combinations of keywords including<br />
low birth weight, guidelines, barriers, attitude,<br />
beliefs, maternal health/nutrition, health services<br />
utilisation, satisfaction and quality of care.<br />
Additional articles were identified and retrieved<br />
by reviewing references in relevant articles.<br />
Further report materials from organisations and<br />
governments were identified manually and found<br />
online.<br />
Only English papers published between 1990<br />
and 2016 were included. Articles pertaining to<br />
women with co-morbidities were excluded as a<br />
separate set of guidelines exist for these mothers<br />
and newborns. Besides the WHO’s guidelines,<br />
only studies relating to LPDR were included.<br />
Furthermore, only studies related to antenatal<br />
care (ANC), perinatal care, postnatal care (PNC)<br />
and breastfeeding (BF) practices with a focus on<br />
LBW were included. The studies were critically<br />
evaluated by looking at the study methodology,<br />
perceived objectivity, study provenance, research<br />
evidence and the contribution of the study to the<br />
literature.<br />
The review was conducted by one author from<br />
February to June 2016 as part of a master thesis.<br />
Subsequently, the LPDR Ministry of Health (MoH)<br />
has launched The National Adolescent and Youth<br />
Friendly Services (NAYFS) guidelines in February<br />
<strong>2018</strong>, to strengthen the capacity for responding<br />
to the needs of adolescent mothers. No significant<br />
changes have been made in WHOs guidelines for<br />
LBW.<br />
Results<br />
Variances between WHO guidelines and<br />
national guidelines in Lao PDR<br />
Variances between WHO’s guidelines and<br />
national guidelines in LPDR are analysed to<br />
see whether LPDR follow the evidence-based<br />
guidelines proposed by WHO. As shown in table<br />
1 below, national guidelines in LPDR are largely<br />
in agreement with WHO guidelines. However,<br />
significant disagreements still exist as highlighted<br />
in the table.<br />
Barriers to guideline adherence in Lao PDR<br />
1. Health sector<br />
Implementation of standard routines such as<br />
weight recording and monitoring of newborn<br />
care is low in LPDR.[1, 45-47] This poses a<br />
significant challenge for effective implementation<br />
of maternal, newborn and child health (MNCH)<br />
services as data can help inform policy makers<br />
about necessary and appropriate changes to<br />
improve access and utilisation of high quality<br />
services to achieve better maternal and LBW infant<br />
outcomes. Duysburg et al. (2014) conducted<br />
interviews with government officials, organisations<br />
and MNCH care providers in LPDR who identified<br />
several implementation barriers. This included the<br />
29
current decentralisation of authority and<br />
responsibilities of the health sector from national<br />
to provincial, district and municipality level, as<br />
well as limited MNCH management capacity and<br />
skills which created confusion regarding roles and<br />
Table 1. Guidelines for LBW in WHO and Lao PDR<br />
WHO<br />
Lao PDR[42-44]<br />
Guidelines[36-41]<br />
ANC<br />
Perinatal<br />
care<br />
PNC<br />
Particular<br />
attention to<br />
vulnerable<br />
women<br />
suffering<br />
4 ANC visits (at<br />
week: 8-<strong>12</strong>, 24-<br />
26, 32, 36-38)<br />
Maternal weight/<br />
height<br />
4 ANC visits (1 per<br />
trimester, third visit<br />
ideally at 36 weeks,<br />
and 4th visit at 40<br />
weeks/term)<br />
Maternal weight<br />
Fetal growth (uterine height)<br />
Promoting<br />
healthy lifestyle<br />
and diet<br />
Support on early<br />
BF and EBF<br />
Counselling on<br />
nutrition<br />
Counselling on BF<br />
Skin-to-skin contact<br />
Advice on early BF<br />
Immediate identification of LBW<br />
Cut-off for<br />
referral -<br />
1500/2000g<br />
1st visit as early<br />
as possible<br />
within 24 hrs if at<br />
home<br />
Care for at least<br />
24 hrs after birth<br />
if in facility<br />
(+) 3 PNC visits<br />
(48 - 72 hr,<br />
7-14d, 6 weeks)<br />
Cut-off for referral -<br />
2000g<br />
1st visit within 24<br />
hours if at home, 24<br />
hrs later if in facility<br />
(+2) PNC visits<br />
(within 7d + 6<br />
weeks)<br />
Counselling on nutrition and EBF for 6<br />
months<br />
Poverty<br />
Young age<br />
Domestic or<br />
gender-based<br />
biolence<br />
Women/<br />
family-friendly<br />
(respecting beliefs<br />
and provision of<br />
quality care)<br />
responsibilities in practice.[46]<br />
Inadequate facilities and equipment for MNCH<br />
care have been reported in LPDR, e.g. lack of<br />
hygiene facilities and weighing scales.[47-49]<br />
Furthermore, lack of skilled health workers[47, 48,<br />
50] has been identified as the highest risk factor for<br />
under-5 mortality in LPDR.[48, 51] Health workers<br />
have reported poor remuneration, insufficient<br />
time, low status, weak technical supervision and<br />
training contributing to low motivation and thus,<br />
poor implementation of MNCH services.[45,<br />
48, 49] Furthermore, guidelines do not propose<br />
guidance in prioritising crucial components in case of<br />
lacking equipment or staff-shortages – an additional<br />
barrier of guideline adherence.<br />
In LPDR, pre-service medical curricula fall under<br />
the Ministry of Education whereas the MoH issues inservice<br />
guidelines. Thus, national guidelines are likely<br />
to be reflected only during in-services rather than preservice<br />
training for health workers. A mixed-methods<br />
study and three qualitative studies involving mothers<br />
and MNCH care providers found a lack of awareness,<br />
understanding, availability and adherence to some<br />
key MNCH policies and guidelines.[46, 48, 49, 52]<br />
An average consultation time of only 5 min was<br />
reported.[49] This suggests that guidelines might be<br />
used minimally or incorrectly due to time constraints<br />
and/or availability. However, due to small sample<br />
sizes generalisability of results might be limited.<br />
2. Mothers and cultural factors<br />
For most care procedures, coverage declines<br />
with lower education status’ and wealth level.[50,<br />
53-57] This explains the lower coverage in rural<br />
areas compared to urban areas (Table 2).[1, 46, 58]<br />
Additional barriers of MNCH care utilisation in such<br />
socio-economic settings include infrastructural and<br />
financial constraints such as transport time and costs.<br />
[46-48, 50, 54, 56, 58-62]<br />
Mothers with inadequate knowledge of healthy<br />
pregnancy practices carry an eight-fold increased<br />
risk of developing LBW infants in LPDR.[25] Reported<br />
reasons for delaying or not receiving MNCH services<br />
include a lack of time, feeling in sufficient health[56],<br />
embarrassment[56, 60], reluctance towards male<br />
nurses[47, 58, 59] and a lack of privacy during care.<br />
[59, 63] Both mothers and health workers have<br />
also reported ethnic discrimination, possibly due<br />
to language barriers.[47, 48, 60] Other barriers for<br />
MNCH care attendance found in the literature include<br />
prolonged waiting times,[47, 56, 61] poor attitude<br />
and quality of care provided by health workers’[57,<br />
59] and misconceptions about ANC usefulness.[56]<br />
Home births are still frequent in LPDR[50, 53, 54,<br />
58, 61] due to the convenience of traditional practices<br />
and lower costs.[48, 58, 59] However, traditional<br />
practices can be unbeneficial and contribute to<br />
delayed or under-utilisation of MNCH services.[48,<br />
53, 54, 62, 64] Traditions include roasting, entailing<br />
resting on a ‘hot bed’ or chair over a fire for up to 4<br />
weeks[30, 31, 52, 61, 64], diet restrictions[29-31, 52,<br />
61, 64], discarding colostrum[31], and complementary<br />
feeding, e.g., rice, water and porridge.[30, 31, 52,<br />
64-69] Interestingly, influence of the husband, and<br />
female relatives[31, 48, 52, 57-60, 62, 63, 65, 70, 71]<br />
have been found as both a threat and facilitator to<br />
uptake and progress of evidence-based practices.<br />
[48, 52, 72] However, most studies were conducted<br />
in rural areas. Adaptation to modern practices seems<br />
to be increasing and conducive for BF promotion in<br />
some rural[69, 73] and urban areas.[47, 52] This has<br />
been reinforced and facilitated by increased access to<br />
health care[30, 52, 64, 65] and skilled health workers.<br />
30
[31, 52, 55, 65, 70]<br />
Traditionally, colostrum is discarded and<br />
formula milk, water or pre-chewed rice are instead<br />
fed the first days thus reducing early BF.[30,<br />
31, 64-66] Though, Lee et al. (2013) found that<br />
most urban first-time mothers recognized the<br />
importance and low cost of colostrum compared<br />
to infant formula.[52] Furthermore, this could be<br />
facilitated by better access to health care.[30, 52,<br />
64] Lack of EBF practice has been identified as the<br />
second highest risk factor for under-5 mortality<br />
in LPDR.[51] Based on national representative<br />
Lao Social Indicator Survey data, two studies<br />
found a significant association between Hmong<br />
ethnicity, EBF for 6 months[65] and higher child<br />
weight-for-height scores, all of which indicate<br />
better nourishment amongst Hmong ethnicity.<br />
[74] On the other hand, complementary feeding<br />
before the age of 6 months is widespread and<br />
varies in introduction and diversity among ethnic<br />
groups. This is a prime factor for suboptimal<br />
infant feeding practices, contributing to stunting.<br />
[30, 31, 64, 70, 75-77] The caregivers’ ethnicity<br />
therefore needs to be considered in provision of<br />
nutrition/feeding counselling. A facilitating factor<br />
for EBF for 6 months could be involvement and<br />
Table 2. Coverage of interventions: early BF, EBF,<br />
ANC, skilled birth attendants, iinstitutional delivery<br />
and PNC<br />
Lao PDR<br />
Total Urban Rural<br />
Early BF (within 1hr of birth), % 39.1 46.7 36.9<br />
EBF for 6 months, % 40.4 39.2 41.0<br />
Antenatal care (>4visits), % 36.9 70.6 27.2<br />
Skilled attendant at birth, % 41.5 79.6 30.7<br />
Institutional delivery, % 37.5 74.2 27.0<br />
PNC for newborns within 2 7.4 <strong>12</strong>.6 5.9<br />
days after delivery, %<br />
Sourced from: Lao Social Indicator Survey 2011-20<strong>12</strong>.[1]<br />
encouragement from the father.[70, 75]<br />
3. Inconsistence/Confounding policies for LBW<br />
prevention and care<br />
Enforcement, monitoring and compliance with<br />
the International Code of Marketing of Breastmilk<br />
Substitutes (BMS)[78] is lacking and subsequently<br />
undermining the promotion of EBF for 6 months in<br />
LPDR,[75, 79-81] in particular, among low-literate<br />
women.[82] Frequent and common violations of<br />
the code are; BMS companies affiliating with health<br />
workers[83], biased and misleading information<br />
on labelling and systematic advertising and<br />
promotion in public hospitals and health facilities.<br />
[70, 75, 80]<br />
Another confounding policy is the presence<br />
of 3 months paid maternity leave. In case of<br />
illness, women workers are entitled to 30 days<br />
supplementary leave whereby approximately<br />
50% of normal pay is provided.[84] Furthermore,<br />
up until one year postpartum, women workers<br />
are entitled daily one-hour breaks to care for the<br />
child. However, some mothers have expressed a<br />
lack of workplace support as a major barrier for<br />
EBF.[52, 73] Thus, aligning current guidelines<br />
with the International Labour Organisation’s<br />
recommendation of 14 weeks maternity leave<br />
could be conducive for promotion of EBF for<br />
6 months and reducing LBW morbidity and<br />
mortality.[80]<br />
Discussion<br />
As evident from this study, developing coherent<br />
guidelines and aligning strategies preventing LBW<br />
is difficult at national and international levels.<br />
Even more challenging is implementation of such<br />
guidelines where it is most needed, i.e. in countries<br />
with high prevalence of LBW and neonatal<br />
morbidity and mortality. A study conducted<br />
in three central hospitals in LPDR suggested<br />
some improvements of LBW care through the<br />
implementation of the WHO Pocketbook of<br />
Hospital Care for Children over a 1-year period.<br />
[85] The appropriateness of current guidelines for<br />
the prevention and management of LBW infants<br />
in LPDR will be discussed, with emphasis on areas<br />
of improvement if better coherence was present.<br />
Appropriate cut-off for referral of LBW<br />
Different cut-offs for referral of LBW infants<br />
were found in two current WHO WPR documents:<br />
a 2000g cut-off and a 1500g cut-off in the WHO<br />
WPR Action Plan 2014-2020[39] and the WHO<br />
WPR EENC guide (2014),[86, 87] respectively.<br />
This demonstrates disparity within a pronounced<br />
organisation. Due to low resources and poor<br />
referral functions in LPDR, a higher cut-off for<br />
referral (2000g) would not necessarily lead to<br />
a better outcome in practice. However, LPDR<br />
could consider introducing an alternative growth<br />
assessment for when scales are not available,<br />
in particular in rural areas. Measuring chest<br />
circumference was in rural India found as the best<br />
surrogate parameter for identifying LBW infants.<br />
[88] Additionally, this could help strengthen<br />
timely referral and avoid unnecessary referrals<br />
burdening the referral centers.<br />
Qualifying as a LBW infant might not necessarily<br />
increase risk of mortality - known as the LBW<br />
paradox.[89, 90] In LPDR, factors such as high<br />
altitude may be a risk factor for LBW, but not<br />
necessarily for mortality.[89, 90] Knowledge on<br />
the predominant distribution (weight distribution<br />
of term births) and the residual distribution<br />
(percentage of small and preterm births) are hence<br />
essential in gaining insight into the gestationalage<br />
characteristics. Such epidemiological data is<br />
necessary to provide a better basis to judge the<br />
appropriateness of cut-off values.<br />
31
Appropriate number and timing of ANC visits<br />
Despite WHO recommending 4 ANC visits[37],<br />
the exact timing of ANC visits has been debatable.<br />
[91] The recommendation is based on a large WHO<br />
ANC randomized trial comparing the standard<br />
model of ANC (<strong>12</strong> visits) with the new ANC model<br />
(4 visits). No differences in maternal and perinatal<br />
outcomes were found between the two models.[92]<br />
A systematic review of studies from developed and<br />
developing countries provided similar findings where<br />
good perinatal outcomes persisted despite reduced<br />
ANC visits.[93] However, it proposed that in a setting<br />
of low ANC-coverage, visits should not be reduced<br />
without close monitoring of foetal and neonatal<br />
outcomes.[93]<br />
The recommendation of 4 ANC visits might be<br />
inappropriate for LPDR due to a lack of financial and<br />
human resources. However, the unspecified timing of<br />
ANC visits in LPDR might be appropriate, as it seems<br />
unrealistic for mothers to adhere and attend ANC at<br />
specific times due to the infrastructural and financial<br />
constraints. However, recommending the 4th visit<br />
at week 40/term might delay or miss detection and<br />
management of LBW births as 44 % of neonatal deaths<br />
are due to prematurity.[94] Conversely, reducing ANC<br />
to 3 visits could reduce maternal satisfaction with<br />
ANC which has been evident from the systematic<br />
review comparing the two ANC models.[93] Declining<br />
satisfaction can adversely influence ANC attendance<br />
and thus, the burden of LBW.<br />
A pre-requisite for appropriate ANC guidelines<br />
is improvement in the quality of resources and<br />
services at both structural levels (e.g., distribution of<br />
guidelines and human resources), and in practice (e.g.,<br />
education, training and adherence to guidelines).<br />
Otherwise, a discussion of recommending 3 or 4<br />
visits is unreasonable.<br />
Appropriate number and timing of PNC visits<br />
A Cochrane review conducted by Yonemoto et al<br />
(2013), found no strong evidence associating frequency<br />
and timing of home-visits with improvements in<br />
neonatal and maternal mortality.[95] However,<br />
this review found 4 studies providing evidence to<br />
suggest that home visits may encourage women to<br />
EBF. On the contrary, an association between home<br />
visits and increased maternal satisfaction with PNC<br />
was described. This suggests PNC is beneficial in<br />
alleviating the burden of LBW. Unlike the WHO, the<br />
MoH in LPDR does not recommend a PNC visit at<br />
7-14 days. Considering the high neonatal mortality<br />
within the first week of life,[96, 97] a PNC visit at<br />
7-14 days might be inappropriate. Furthermore, the<br />
current LPDR PNC schedule articulates well with the<br />
Expanded Programme on Immunisation.[98] However,<br />
due to the low rate of EBF and growing importance<br />
of educating mothers in feeding practices for LBW<br />
infants, a recommendation of PNC visit at 7-14 days<br />
could be appropriate. Adding a PNC visit should<br />
be considered only after evaluating availability of<br />
resources and assessing morbidity and mortality risk<br />
after the first week of life. Thus, the focus should be<br />
on content and quality of care to facilitate optimal BF<br />
practices as opposed to increasing PNC visits, which<br />
carry costs towards the mother and society without<br />
documented benefit.<br />
Attention to vulnerable women<br />
WHO guidelines[37] mention vulnerable women,<br />
including adolescents, as a group that needs<br />
special attention. Low maternal age (
eview suggested that structural factors including<br />
culture, infrastructure and economy appeared to<br />
be major barriers for adherence and acceptance of<br />
guidelines.<br />
In the context of barriers and facilitators for<br />
implementation of LBW guidelines, appropriateness<br />
of LBW guidelines needs further research. However,<br />
4 ANC visits in LPDR were found appropriate due<br />
to the risk of decreasing satisfaction and thus<br />
utilisation of ANC if reduced to 3 ANC visits. In line<br />
with recommendations by the WHO, BF and skinto-skin<br />
contact were found appropriate for LPDR<br />
given its potential to reduce the burden of LBW<br />
morbidity and mortality in low-resource settings.<br />
A recommendation is made on implementing<br />
culturally acceptable maternity waiting homes due<br />
to strong and widespread cultural practices in LPDR.<br />
The internal institutional alignment and coherence<br />
of guidelines, particularly the cut-off for referral of<br />
LBW infants, should also be monitored to ensure<br />
hard-working healthcare workers are appropriately<br />
informed of appropriate practices and complications<br />
of nonadherence. Further studies comparing<br />
divergent WHO guidelines, local guidelines and local<br />
cultural norms and traditions are recommended for<br />
future studies.<br />
Acknowledgments<br />
None<br />
Declarations<br />
The materials used during the current study<br />
are available from the corresponding author<br />
on reasonable request. The author declares that<br />
submissions are neither intentionally nor able to<br />
be construed as defamatory or unfairly derogatory<br />
of any persons or organisations.<br />
Conflicts of Interest<br />
None declared<br />
Correspondence<br />
linemp89@gmail.com<br />
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35
“<br />
The experience of Mekelle University in provision of<br />
comprehensive healthcare interventions at STI clinics<br />
for female sex workers in Ethiopia<br />
Review article<br />
Tesfay Gebregzabher Gebrehiwot<br />
Dr. Gebregzabher Gebrehiwot has been working as a nurse and non physician<br />
clinician. Additionally working in the zonal health department, district<br />
health office and regional health bureau in the health system organization,<br />
Dr Gebregzabher Gebrehiwot is currently working as Head of Public Health<br />
at Mekelle University.<br />
Abstract<br />
Background: Evidence suggests that the presence of untreated sexually transmitted infections (STIs)<br />
increases the chance of human immunodeficiency virus (HIV) transmission during unprotected sex.<br />
In the Ethiopian context, many female sex workers live in poor conditions in rented slums and are<br />
not typically known or recognised by local authorities, making them unable to access health facilities.<br />
Methods: Data were obtained from a register of female sex workers recorded for purpose of service<br />
provision at confidential STI clinics in Mekelle and Adigrat, Ethiopia, from May 2010 to August 2015<br />
and from May 2011 to August 2015, respectively. A simple descriptive analysis of services delivered<br />
to patients was performed.<br />
Results: Among the 6288 patients included in this study, the prevalence of STIs was 23.4%. Of these,<br />
<strong>12</strong>.9% (814/6288) of patients presented with vaginal discharge, 7.9% (490/6288) with genital ulcers<br />
and 2.3% (158/6288) with lower abdominal pain (as per the World Health Organisation (WHO)<br />
syndromic approach to STIs). Moreover, 180 cases of genital ulcer were tested for syphilis with the<br />
Venereal Disease Research Laboratory (VDRL) test; 36 (20%) tested positive for active infection. The<br />
HIV prevalence declined from 10% in 2010 to 1.1% in 2015. The frequency of STIs amongst repeat<br />
patients was considerably lower than that in new presentations.<br />
Conclusions: Clinic and workplace geography, hours of clinic operation, confidentiality and peer<br />
outreach are important factors in the prevention and control of STI/HIV infection in key female sex<br />
worker populations. A comprehensive clinic intervention enhances early diagnosis and treatment of<br />
STIs and increases the proportion of female sex workers accessing HIV treatment services.<br />
Introduction<br />
Additonal authors: Dejen Yemane, Zerihun Abebe, Solomon Gmariam,<br />
Yemane Ashebir, Afework Mebrat, Alemayehu Mekonen & Loko Abrham<br />
Sexually transmitted infections (STIs) are<br />
among the most common causes of illness in<br />
the world, and have far-reaching health, social,<br />
and economic consequences.[1, 2] STIs affect<br />
the health and social wellbeing of women by<br />
compromising their reproductive potential, with<br />
women of reproductive age and adolescents<br />
most affected. Women often feel uncomfortable<br />
discussing issues regarding sexuality, potentially<br />
resulting in further disempowerment in<br />
developing countries. STIs create a significant<br />
health and economic burden, especially for<br />
developing countries, where they account for<br />
17% of economic losses caused by ill-health.[3,<br />
4]<br />
Management of STIs in many developing<br />
countries has been complicated by the lack of<br />
simple and affordable diagnostic tests. STIs often<br />
exist without symptoms; for example, up to 70%<br />
of women with gonococcal and/or chlamydial<br />
infections may be asymptomatic.[5, 6] human<br />
immunodeficiency virus (HIV) remains one of<br />
the most important STIs in developing countries,<br />
in part due to high prevalence and associated<br />
social, economic, and health burdens. It is wellestablished<br />
that the concomitant presence<br />
of non-HIV STIs increases the transmission of<br />
”<br />
36
HIV during unprotected sex.[5-8] Therefore,<br />
effective prevention messages, treatment for<br />
concomitant STIs, and promotion of condoms in<br />
such populations can have a substantial impact<br />
on HIV transmission.[8-10]<br />
STIs and the Ethiopian context<br />
STIs remain a major public health threat in<br />
Ethiopia, with most cases affecting adolescents<br />
and young adults.[11, <strong>12</strong>] Indeed, STIs are<br />
grossly underreported in Ethiopia, largely<br />
because these infections have traditionally been<br />
stigmatised, many infections are asymptomatic<br />
and diagnostic and treatment facilities are<br />
scarce. As a result, many patients with STIs<br />
seek treatment in various settings, including<br />
traditional healers, pharmacists, and informal<br />
drug-vendors and marketplaces, none of which<br />
report cases to the Ministry of Health. As with<br />
many countries internationally, STIs in Ethiopia<br />
have become a more complex issue in recent<br />
years, in part reflecting changing attitudes with<br />
respect to risk behaviours.[13, 14] Not only has<br />
prostitution become more open and widespread,<br />
but increasing poverty, postponement of<br />
marriage, urbanisation, socio-cultural change,<br />
and increasing youth unemployment have<br />
contributed to earlier and often unprotected sex.<br />
[7, 8, 11, 15-17]<br />
Rationale for the intervention<br />
Female sex workers (FSWs) are particularly<br />
vulnerable to the changing sociocultural<br />
environment in Ethiopia, due to ongoing<br />
stigmatisation, economic disadvantage, and a<br />
high rate of sexual partner turnover. Consequently,<br />
FSWs pose a high risk of transmitting these<br />
infections to their clients and other sexual<br />
partners.[18] Although some reports indicate<br />
that condom use by FSWs with paying clients<br />
has increased in recent years, there remains<br />
concern that condom use with non-paying<br />
partners is low.[19, 20] This is a serious gap in<br />
sexual health practices: non-paying partners can<br />
transmit HIV and other STIs from FSWs to the<br />
general population. Furthermore, the number of<br />
FSWs in regional towns has increased. As a result,<br />
the average age of FSWs has shifted towards<br />
younger women, with a consequent decrease<br />
in understanding and implementation of safe<br />
sexual practices.[19, 21-24]<br />
The majority of FSWs live in poor conditions<br />
in rented slums, with limited access to services.<br />
Even if they have access to health facilities, they<br />
cannot afford to pay bills for drugs and diagnostic<br />
services.[25-27] Improving access to STI clinics<br />
in such areas can mitigate the socioeconomic<br />
barriers faced by FSWs, thus increasing capacity<br />
to treat STIs and prevent HIV transmission.[28,<br />
29]<br />
To address gaps in sexual health services<br />
in these communities, the College of Health<br />
Sciences at Mekelle University has entered into<br />
a cooperative agreement with the Centers for<br />
Disease Control and Prevention (CDC) Ethiopia/<br />
Atlanta from 2009 to 2014.[30] The purpose<br />
of this paper is to evaluate the outcome of<br />
a comprehensive STI/HIV prevention and<br />
treatment service, and to quantify STI/HIV cases<br />
in FSWs visiting the confidential clinics in Adigrat<br />
and Mekelle.<br />
Methods<br />
Data were collected from a register of FSWs<br />
recorded for purpose of service provision at<br />
confidential STI clinics in Mekelle and Adigrat,<br />
Ethiopia, from May 2010 to August 2015 and<br />
from May 2011 to August 2015, respectively.<br />
Following consultation with authorities at<br />
the Tigray Regional Health Bureau, the first<br />
confidential STI clinic was established in Mekelle<br />
in May 2010, functioning under the College of<br />
Health Sciences, Mekelle University. The second<br />
STI clinic was established in Adigrat town, where a<br />
high number of FSWs reside, due to its proximity<br />
to the Eritrean border and consequent military<br />
population.<br />
Typically, a client visiting the clinic is evaluated<br />
according to her presenting complaint for<br />
common STI syndromes, as per the WHO<br />
syndromic approach to STIs. The syndromic<br />
approach reduces the requirement for costly<br />
and time-intensive diagnostic procedures by<br />
assigning probabilistic STI diagnoses to patients<br />
presenting with specific symptoms in the<br />
context of high-risk behaviours. In particular, the<br />
syndromes evaluated in this paper include vaginal<br />
discharge syndrome (gonorrhoea/chlamydia,<br />
and other genitourinary pathogens), genital<br />
ulcer syndrome (syphilis), and lower abdominal<br />
pain (presumed pelvic inflammatory disease).<br />
Using this approach, patients receive treatment<br />
according to the pathogens of greatest concern,<br />
as listed above.<br />
Owning to the unique nature of the clinic,<br />
there is no sign for the confidential STI clinic;<br />
FSWs visit the clinic only through peer referrals<br />
made by specifically trained peer promoters<br />
who are FSWs themselves. More than 250<br />
trained FSWs educate their peers on STIs/HIV<br />
and refer cases for treatment and care to the<br />
clinic. Importantly, when needed, clients are<br />
routinely provided with a range of contraceptive<br />
options including condoms, targeted health<br />
education and antibiotics, all free of charge.<br />
Follow up appointments and consultations with<br />
a dermato-venerologist are also made when<br />
necessary for cases that require continuation<br />
of care. Regulatory checks of equipment, drugs<br />
and laboratory resources have been performed<br />
to ensure standards of care are maintained, and<br />
37
ongoing review is enabled by fortnightly meetings.<br />
Data retrieval and analysis<br />
Data pertaining to consultations and service<br />
provision were obtained from a registration book<br />
in the confidential STI clinic. New and repeat clients<br />
were tabulated separately and categorised based on<br />
the type of services provided. Thereafter, data were<br />
recorded in an Excel sheet and a simple descriptive<br />
analysis was performed. Data are presented as<br />
frequency (percentage) unless otherwise stated.<br />
This study received ethics approval from the<br />
Mekelle University College of Health Sciences Ethics<br />
Committee (approval number ERC0027/2011), who<br />
waived the necessity for written informed consent<br />
given the nature of the data presented.<br />
Results<br />
STI statistics - Mekelle<br />
The Mekelle STI clinic provided sexual health<br />
services to 2549 new clients during the 5-year study<br />
period (2010-2015), of which 889 (34.9%) were<br />
diagnosed with and treated for an STI. As per the<br />
WHO syndromic approach to STIs, the most common<br />
diagnosis was vaginal discharge syndrome (n = 445,<br />
50.1%). Genital ulcers were noted in 381 women<br />
(42.9%). Relatively few women were diagnosed<br />
with lower abdominal pain (n = 63, 7.1%). Of note,<br />
throughout the 5-year study period, only 15 repeat<br />
clients presented with STI infection, suggesting that<br />
the preventative practices promoted by the service<br />
and peer workers were effective.<br />
In the first year at Mekelle clinic, a total of 891 new<br />
FSWs were examined from May 2010 to August 2011,<br />
of which 302 (33.9%) were diagnosed with and treated<br />
for an STI (Table 1). Most women were in the 15-29<br />
age group (n = 710, 79.7%). Of the 302 cases with an<br />
STI, <strong>12</strong>2 manifested with 1 of the 3 STI syndromes:<br />
genital ulcer, 56 (45.9%); vaginal discharge, 54<br />
(44.2%); and lower abdominal pain, <strong>12</strong> (9.8%).<br />
Moreover, 180 cases were tested for syphilis with the<br />
Venereal Disease Research Laboratory (VDRL) test, of<br />
which 36 (20%) tested positive for active infection.<br />
The remaining cases were managed empirically as<br />
per the WHO syndromic approach. Unfortunately,<br />
the true prevalence of active syphilis could not be<br />
accurately assessed, due to a lack of VDRL reagents,<br />
and a consequent lack of consistent testing amongst<br />
clients. The prevalence of STIs rose significantly<br />
during the second year of the project (2011-20<strong>12</strong>),<br />
with 301 (76.9%) of all new clients screened (n =<br />
391) found to have an STI. During the subsequent<br />
years, the prevalence of STIs ranged from 29-34.8%.<br />
In 2014-2015, the prevalence reduced rapidly from<br />
30% to 17%; of 468 FSWs screened, only 80 STI cases<br />
were diagnosed and treated (Table 2). The number<br />
of FSWs (new and repeat clients) visiting the Mekelle<br />
STI clinic increased considerably throughout the<br />
study period; however, the number of new clients<br />
remained relatively constant throughout the 5-year<br />
study period.<br />
STI statistics – Mekelle and Adigrat<br />
As discussed above, the Adigrat clinic was not<br />
established until the second year of the study. The<br />
total number of screened cases among the 2 sites<br />
was 6288, with 1462 STI cases diagnosed and treated.<br />
The prevalence of STIs throughout the 5-year study<br />
duration at both sites was 23.4%. Based on the WHO<br />
syndromic approach, 814 (55.7%) patients were<br />
diagnosed with vaginal discharge syndrome, 490<br />
(33.5%) with genital ulcer syndrome, and 158 (10.8%)<br />
with lower abdominal pain. Inferences regarding<br />
the distribution of causative pathogens can be<br />
made according to the WHO syndromic approach,<br />
as discussed above. Of all diagnosed STIs, vaginal<br />
discharge syndrome was present in more than half<br />
of patients.<br />
HIV counselling and testing service<br />
From May 2010 to August 2011, of 598 women<br />
who attended the Mekelle clinic, 55.7% (n = 333)<br />
were provided HIV testing and counselling. Of FSWs<br />
recruited for opportunistic screening, 48 (14.4%)<br />
had positive HIV results. The remaining individuals<br />
declined testing; many of these women claimed that<br />
Table 1. Trends in STI presentations to Mekelle STI clinic from May 2010-August 2011<br />
Age FSWs Treated STI syndromes<br />
for STI Vaginal discharge Genital ulcer Lower abdominal pain<br />
45 17 18 2 4 3<br />
Total 891 302 54 56 <strong>12</strong><br />
FSWs, female sex workers; LAP, lower abdominal pain. *NB: Not all patients were diagnosed using the STI syndrome approach,<br />
therefore, discrepancies may exist in frequency tallies.<br />
38
the test had been performed within the previous 3<br />
months, however, several women also refused to be<br />
tested due to the fear of stigma and discrimination<br />
associated with a positive test. On subsequent<br />
follow-up for those women who refused screening,<br />
further opportunities for screening were offered,<br />
as appropriate. All FSWs who received a positive<br />
test result for HIV were referred to higher health<br />
institutions for antiretroviral therapy (ART) and to<br />
other organisations for related services.<br />
When both clinics were included, a total of<br />
5302 FSWs were tested for HIV over the 5-year<br />
study duration, with 181 having positive results,<br />
giving a prevalence of 3.4%; however, of those also<br />
diagnosed with an STI (n = 1462), the prevalence was<br />
<strong>12</strong>.4% (Table 3). This suggests that concomitant STI<br />
infection is a risk factor for HIV infection. Notably,<br />
the prevalence of HIV decreased from 10% in 2010<br />
to 1.1% in 2015 (Table 4).<br />
Discussion<br />
This study aimed to describe the experience of 2<br />
confidential sexual health clinics in northern Ethiopia,<br />
and to quantify the prevalence of STIs and response<br />
to education regarding preventative health activities.<br />
The link between STI and HIV co-infection was<br />
examined, with an increased rate of HIV infection<br />
noted in those presenting for investigation of an STI<br />
syndrome, as consistent with previous literature.<br />
Establishing the clinic and peer outreach<br />
In the first 2 months following establishment of the<br />
clinic, the number of FSWs attending was minimal.<br />
Subsequent efforts to educate peer promoters were<br />
successful in increasing the number of FSWs accessing<br />
services at the clinics. Furthermore, staff working<br />
at the clinic also played a role in disseminating<br />
key information to FSWs during outreach sessions.<br />
During the 5-year period, different strategies were<br />
implemented to mobilise FSWs for HIV testing and<br />
counselling. Providing peer education, engaging<br />
with bar and hotel owners, conducting forums with<br />
various stakeholders, providing outreach services and<br />
opening the STI clinics on weekends were among the<br />
strategies used, with good effect.<br />
The Mekelle STI clinic provided sexual health<br />
services to 2549 new clients during the 5-year study<br />
period (2010-2015), of which 889 (34.9%) were<br />
Table 2. Provision of STI services at Mekelle STI clinic from 2010 to 2015<br />
Screening STI syndromes Contraceptives and interventions<br />
Year Total<br />
visits<br />
Screened VDS GUS LAP Condoms<br />
provided<br />
Depo OCP Pregnancy<br />
test<br />
New Rpt New Rpt New Rpt New Rpt Visits Condoms<br />
2010 803 500 303 39 0 60 0 6 2 650 65,000 111 18 42<br />
2011 4059 391 3668 148 2 <strong>12</strong>6 0 27 1 3468 499,392 502 285 282<br />
20<strong>12</strong> 5691 710 4981 <strong>12</strong>6 1 68 0 13 1 4520 594,100 791 342 436<br />
2013 5474 502 4972 53 1 77 2 10 1 4<strong>12</strong>2 618,300 808 306 360<br />
2014 2388 446 1942 79 2 50 1 7 1 3922 595,800 1153 388 526<br />
2015 <strong>12</strong>29 468 761 52 0 26 0 2 0 1548 154,800 799 242 361<br />
Total 18415 2549 15866 445 6 381 3 63 6 16682 2,372,592 3365 1339 1646<br />
VDS, vaginal discharge syndrome; GUS, genital ulcer syndrome; LAP, lower abdominal pain; OCP, oral contraceptive pill;<br />
Depo, Depo-Provera contraceptive injection.<br />
Table 3. HIV testing and STI screening at Mekelle and Adigrat clinics<br />
Screening STI syndromes Treated STIs HIV tested<br />
Year Total Screened VDS GUS LAP New Rpt New 1 HIV+<br />
visits New Rpt New Rpt New Rpt New Rpt<br />
2010 803 500 303 39 0 60 0 6 2 650 65,000 111 18<br />
2011 4619 951 3668 199 2 135 0 57 1 3468 499,392 502 285<br />
20<strong>12</strong> 8003 2373 5630 229 1 102 0 57 1 4520 594,100 791 342<br />
2013 7841 930 6911 <strong>12</strong>7 1 92 2 18 1 4<strong>12</strong>2 618,300 808 306<br />
2014 4494 814 3680 146 2 66 1 14 1 3922 595,800 1153 388<br />
2015 2165 720 1445 74 2 35 0 6 0 1548 154,800 799 242<br />
Total 27925 6288 21637 814 8 490 3 158 6 16682 2,372,592 3365 1339<br />
NB: 2010 refers to the Mekelle clinic alone, as Adigrat was not in operation until 2011. VDS, vaginal discharge syndrome;<br />
GUS, genital ulcer syndrome; LAP, lower abdominal pain.<br />
1. Only new patients receiving HIV tests have been included here.<br />
39
Table 4. HIV prevalence among female sex workers<br />
attending the STI clinics (Mekelle & Adigrat), 2010-<br />
2015<br />
Year<br />
2010 2011 20<strong>12</strong> 2013 2014 2015<br />
Number of FSWs 200 626 1514 <strong>12</strong>00 950 8<strong>12</strong><br />
tested (HCT)<br />
Positive cases 21 52 42 26 27 13<br />
diagnosed with and treated for an STI. In general,<br />
the number of consultations for FSWs, particularly<br />
for repeat clients, grew throughout the study. The<br />
overall STI positivity rate among FSWs who received<br />
care at the STI clinics remained stable. Similar FSWspecific<br />
STI clinics in Uganda have reported rates<br />
of STIs approaching 70%.[31] This difference could<br />
be explained by the study setting, in particular the<br />
abovementioned clinics in Uganda were located<br />
in major commercial centres, and lacked the peer<br />
education component delivered in the Ethiopian<br />
clinics. The prevalence of STIs throughout the 5-year<br />
study duration at both sites (Mekelle and Adigrat) was<br />
23.4%. This finding is consistent with other studies<br />
conducted among FSWs in Finote Selam (Ethiopia)<br />
and Malawi, where the prevalence of STIs were 20.6%<br />
and 25%, respectively.[18, 24] However, STI rates in<br />
Ethiopia vary considerably; for example, 47.9% of<br />
FSWs were found to have an STI in Addis Ababa.[13]<br />
Similar international FSW-specific clinics have<br />
reported much lower rates of STI positivity, such as in<br />
the Netherlands (9.5%).[32] A combined intervention<br />
focusing on peer education, voluntary and<br />
anonymous clinic attendance, condom promotion<br />
and STI testing, as administered in this study, has<br />
previously been successful in decreasing STI rates<br />
in other African countries, such as Côte d’Ivoire and<br />
Benin,[33, 34] and internationally in India.[27, 29]<br />
HIV counselling and testing service<br />
Of all FSWs who attended the Mekelle clinic in 2010<br />
(n = 598), 333 (55.7%) were provided HIV testing and<br />
counselling, with 48 (14.4%) returning positive HIV<br />
results. The remaining individuals declined testing.<br />
Sex workers face stigma and discrimination in<br />
different forms; for example, it is common for FSWs<br />
to be exposed to violence and social discrimination.<br />
FSWs are highly vulnerable to HIV due to high risk<br />
sexual behaviours; limited access to HIV prevention,<br />
diagnosis, and treatment services; high-level stigma<br />
associated with sex work; and social and economic<br />
marginalization.[13, 26, 35] Despite growing efforts<br />
to increase HIV testing and counselling services for<br />
the most at-risk populations in Ethiopia, the uptake<br />
of such services by FSWs remains poor. Previous<br />
studies in Zambia and Ethiopia have shown that lack<br />
of confidentiality is a major barrier to HIV testing.[35,<br />
36]<br />
Over the 5-year study period at both clinics, the<br />
prevalence of HIV was 3.4%, with a concomitant<br />
STI infection rate of <strong>12</strong>.4%. The prevalence of HIV<br />
exhibited a marked decline from 10% in 2010 to 1.1%<br />
in 2015. This finding is lower than a previous baseline<br />
survey in Ethiopia conducted from 1989 to 1990,<br />
which reported a mean sero-prevalence of 17%.[23]<br />
The current study observed a marked decline in HIV<br />
prevalence. This is consistent with studies conducted<br />
in Adama, Ethiopia.[26] Such a decline likely reflects<br />
a number of factors, including increased accessibility<br />
to ART, but also a decline in the prevalence of STIs<br />
and condom promotion.<br />
Lessons learned<br />
Good connection and collaboration with the<br />
community is required to mobilise services for<br />
vulnerable populations. Furthermore, maintaining<br />
confidentiality is crucial in building and maintaining<br />
rapport. Whilst traditional services are typically<br />
inaccessible for FSWs and similar vulnerable<br />
populations, the model described in this paper<br />
provides a realistic and reproducible approach to<br />
preventative health for FSWs. Collaboration with<br />
appropriate governmental and non-governmental<br />
stakeholders is required to guarantee the<br />
sustainability of such services.<br />
Future directions<br />
After establishment of the clinics, high service<br />
demand was observed. Such demand requires<br />
mapping and census of FSWs, with the view to<br />
increase the number of confidential STI clinics in<br />
areas with the greatest need. The preliminary results<br />
observed in this study suggest that it is possible<br />
to reduce the burden of STIs and HIV by provision<br />
of targeted health interventions for vulnerable<br />
populations, using a model that is cognisant of<br />
the unique demands FSWs face. Further research<br />
is needed to both confirm the results observed in<br />
this study, and to explore aspects of stigma and<br />
discrimination faced by FSWs when seeking medical<br />
advice from traditional health providers.<br />
Conclusion<br />
The HIV prevalence declined from 10% in 2010 to<br />
1.1% in 2015. Compared to new cases, the frequency<br />
of STIs among repeat clients was extremely low,<br />
suggesting that the cumulative effect of peer<br />
promotion and preventative sexual health education<br />
is effective in reducing the rates of STIs among<br />
vulnerable populations. The clinic intervention<br />
enhances early diagnosis and treatment of STIs, and<br />
increases the proportion of FSWs linked with ART<br />
services. Therefore, it is reasonable to suggest that<br />
such an approach be encouraged in future models of<br />
service provision.<br />
Author contributions<br />
TG was responsible for conception and design of<br />
the project, completing grant applications,<br />
overseeing project activities and reviewing<br />
data compilation, analysis and composition of<br />
the manuscript. DY was responsible for<br />
coordinating part of the project and involved<br />
40
in data retrieval and manuscript composition. ZA<br />
was responsible for monitoring and evaluating<br />
as a business official, supervising data retrieval<br />
and manuscript composition. SG, YA, AM, AM, and<br />
LK contributed equally in supervision of data<br />
retrieval and manuscript composition.<br />
Abbreviations<br />
AIDS: Acquired immunodeficiency syndrome<br />
CDC: Centers for Disease Control and Prevention<br />
FSWs: Female sex workers<br />
HIV: Human immunodeficiency virus<br />
PEPFAR: President’s Emergency Plan for AIDS<br />
Relief<br />
STIs: Sexually transmitted infections<br />
VDRL: Venereal Disease Research Laboratory<br />
WHO: World Health Organization<br />
Conflicts of interest<br />
None declared<br />
Correspondence<br />
tesfig@gmail.com<br />
Acknowledgments<br />
Provision of sexual health services as discussed in<br />
this manuscript would not have been possible<br />
without funding granted by CDC/PEPFAR; the<br />
authors wish to acknowledge the assistance of the<br />
CDC/PEPFAR in enabling this service. The authors<br />
also wish to acknowledge users of the service, in<br />
particular peer educators who have been pivotal in<br />
mobilizing beneficiaries. Further<br />
acknowledgements go to the College of Health<br />
Sciences at Mekelle University, Tigray Regional<br />
Health Bureau and all project staff members,<br />
in particular clinic staff. Finally, the authors wish<br />
to acknowledge Dr. Belete Assefa (School of Public<br />
Health, Mekelle University) for his support in<br />
editing and reviewing the manuscript.<br />
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ese- and sex-matched non-students.[4] Such a<br />
finding<br />
42
An open letter to our social media overlords<br />
Editorial<br />
Nina Li<br />
Nina Li is a fourth year medical student at the University of New<br />
South Wales. She is passionate about evidence-based medicine<br />
and when she isn’t working with <strong>Vector</strong> Journal, she can be<br />
found drawing instead of paying attention in lectures.<br />
As I scrolled through my Facebook News Feed<br />
on my millennial pink iPhone, I noticed a bitter tone<br />
creeping into my thoughts. A friend was on a European<br />
vacation in Santorini. #blessed. Another friend had<br />
just completed a marathon run in a personal best<br />
time. I’m not sure that I could complete a marathon<br />
even if someone carried me to the finish line.<br />
Someone else had posted an image of the kale and<br />
quinoa power bowl they had consumed for lunch—<br />
complete with cold-pressed juice accompaniment—<br />
and affectionately captioned it “healthy habits”.<br />
Silently stashing away my half-priced, greasy hot<br />
chip lunch on a bus most definitely not in Europe,<br />
I was overcome with feelings of inadequacy and<br />
dissatisfaction. In my mind, none of my achievements<br />
or positive attributes could hold a candle to what my<br />
peers were accomplishing. It was all too easy to forget<br />
the meticulous curation inherent in social media’s<br />
highlights reel of life, complete with the option to<br />
edit out any pesky sharp edges of reality.<br />
I know I’m not alone in having these intrusive<br />
thoughts. As of June <strong>2018</strong>, Instagram has one billion<br />
monthly active users.[1] Let us pause for a second and<br />
consider what this number means. Not one million,<br />
but one billion regular users. One billion individuals<br />
routinely scrolling through images purposefully<br />
presented to make you chuckle, elicit a tear, provide<br />
inspiration, or perhaps trigger self-loathing. One<br />
billion other individuals also stalking beauty gurus,<br />
unintentionally consuming native advertising and<br />
living vicariously through celebrities.<br />
If my mortifying Emo phase has taught me anything,<br />
it’s that adolescence and the turbulent transition<br />
to young adulthood represents a critical time of<br />
self-discovery and emotional maturation. Amidst<br />
continually evolving technological advancement,<br />
young adults come of age in an era where<br />
communicating and expressing one’s individuality (or<br />
lack thereof) on social media platforms is the norm.<br />
[2] Young adults represent the highest proportion<br />
of social media users, with 92% of Australians aged<br />
16–17 years frequenting social media,[3] compared<br />
to only 30% of individuals aged 65 and over.[4]<br />
Considering the centrality of social media in<br />
establishing connections, shaping self-identity and<br />
providing access to a previously unimaginable wealth<br />
of knowledge, its ties to psychological health are<br />
inextricable. Facebook continues to reign supreme<br />
over other user-generated social networking<br />
platforms, which include Twitter, Google+, LinkedIn,<br />
Pinterest, Instagram and Snapchat.[5] Despite its<br />
43
ubiquity, we remain largely ignorant to the potential<br />
mental health ramifications of navigating the social<br />
media minefield.[2] The speed of change has only<br />
widened the distinct generational gap between<br />
the internet-indoctrinated millennials who face the<br />
pressures of this novel online world firsthand and<br />
the law-enforcers and policymakers attempting to<br />
moderate and improve it.<br />
It was all too easy to<br />
forget the meticulous<br />
curation inherent in<br />
social media’s highlights<br />
reel of life, complete<br />
with the option to edit<br />
out any pesky sharp<br />
edges of reality.<br />
Growing up as a so-called ‘digital native’,[6]<br />
my relationship with social media was always<br />
slightly dysfunctional (and occasionally bordering<br />
on Stockholm Syndrome). Each brief jaunt to a<br />
different social networking platform would spark<br />
an uncontrollable spiral of comparison, envy and<br />
self-loathing. Yet while I could rely on social media<br />
to stir up negative emotions within me, it was also<br />
an essential channel of communication for group<br />
projects, organising events and simply chatting with<br />
peers. Try as I might, social media’s utility made it<br />
inescapable; the red notification icon acted like a<br />
time-bomb, ticking upwards until I surrendered<br />
and reopened the apps I had tried so hard to avoid.<br />
Indeed, social media has been described by many<br />
young adults as more addictive than smoking or<br />
alcohol use.[7] In one study involving social media<br />
habits,[8] 5% of young adult participants were<br />
afflicted by social media addiction, fulfilling at least<br />
five of nine DSM-V criterion also used to tentatively<br />
diagnose Internet Gaming Disorder.[9]<br />
common sentiment, known colloquially as FOMO<br />
(Fear Of Missing Out), has alarming associations<br />
with lower mood, greater anxiety and feelings of<br />
inadequacy, and is strongly linked with higher levels<br />
of social media engagement.[10]<br />
Body image remains a significant issue for young<br />
adults and adolescents, with 9 out of 10 girls citing<br />
dissatisfaction regarding their figure.[11] Social<br />
media provides an infinite pool of candidates to<br />
compare oneself to online, all just a click or tap away.<br />
With 80 million photographs uploaded to Instagram<br />
daily,[<strong>12</strong>] young adults are continually bombarded<br />
with heavily edited, meticulously staged images<br />
presented as if they were “natural”. How often have<br />
I found myself subconsciously assessing my worth<br />
through superficial, appearance-based comparisons<br />
using social media? Far more often than I will ever<br />
admit to.<br />
Inevitably, this has significant ramifications. Not<br />
only has perusing Facebook been linked with higher<br />
rates of body image concerns from women and girls,<br />
but also an amplified desire for physical appearance<br />
changes, which may be associated with the increasing<br />
rates of cosmetic surgery in young adults.[2] The<br />
mounting pressure to become this ‘perfect’ individual<br />
can fuel feelings of inadequacy and low self-esteem,<br />
potentially contributing to the rise of anxiety and<br />
depression among young adults.[13] In studies by Lin<br />
et al. (2015) and Sampasa-Kanyinga & Lewis (2015),<br />
youths spending a disproportionate amount of time<br />
(>2 hours) on social media platforms were more likely<br />
to report poor mental health, psychological distress<br />
and suicidal ideation.[14, 15] Researchers have even<br />
coined the term ‘Facebook depression’ to describe<br />
the growing evidence supporting the association<br />
between the unattainable demands of the online<br />
world and poor mental health.[16]<br />
My attempted character assassination of<br />
social media notwithstanding, the substantial<br />
benefits of these novel communication platforms<br />
deserve recognition. Social media have presented<br />
revolutionary opportunities for young individuals<br />
to express themselves and their beliefs. Established<br />
The endless influx of photographic proof that my<br />
friends were leading fulfilling, fun-filled lives made<br />
my own situation feel mundane. Why was I lounging<br />
at home in sweatpants instead of enjoying a night<br />
out with friends? I burdened myself with unhealthy<br />
expectations of matching what I was observing on<br />
social media, lest I fail to live life to its fullest. But<br />
achieving this seemed to demand even more attention,<br />
more self-critical comparisons, more dedication to<br />
the platforms perpetuating this destructive cycle. It<br />
didn’t matter that I barely knew these people on my<br />
social media—they simply provided a benchmark,<br />
however unrealistic, to juxtapose my life against. This<br />
44
in the aftermath of the <strong>2018</strong> Marjory Stoneman<br />
Douglas High School shooting, The Never Again<br />
MSD Movement’s gun control advocacy is a prime<br />
example of social media’s ability to amplify the voices<br />
of young adults in a world where attempting to do so<br />
by conventional means presents difficulties. For many,<br />
social media has revitalized dormant relationships,<br />
strengthened existing friendships and helped form<br />
online support networks that overcome geographical<br />
separation. The ability to connect with like-minded<br />
peers and receive emotional support, especially for<br />
individuals belonging to real-world minority groups,<br />
remains invaluable.<br />
‘How often have<br />
I found myself<br />
subconsciously<br />
assessing my worth<br />
through superficial,<br />
appearance-based<br />
comparisons using<br />
social media? Far more<br />
often than I will ever<br />
admit to.’<br />
Nearly half of all Australians (45%) will experience<br />
a mental illness during their lifetime,[17] with<br />
prevalence remaining the highest amongst Australian<br />
aged 18-24 years (21.2% of all Australians within<br />
this age group).[18] Clearly, these are not paltry<br />
numbers. While research remains sparse, there is<br />
increasing evidence that social media usage may<br />
contribute to psychological distress and poorer<br />
mental health. Since social media services are not<br />
destined for obsolescence anytime soon, a thorough<br />
consideration of their lasting psychological impacts<br />
grows ever more imperative, especially for young<br />
adults and adolescents.<br />
Acknowledgements<br />
None<br />
Photo credits<br />
Image 1: Pixabay, accessed from https://<br />
www.pexels.com/photo/facebook-applicationicon-147413/<br />
Image 2: Thought Catalog, accessed from https://<br />
unsplash.com/photos/xVRdDDe6M1A<br />
Conflicts of interest<br />
None declared<br />
References<br />
1. Christine, J. Instagram hits 1 billion monthly users, up from<br />
800M in September [Internet]. San Francisco US: TechCrunch; <strong>2018</strong><br />
[updated <strong>2018</strong> June 20; cited 20<strong>12</strong> Nov 20]. Available from: https://<br />
techcrunch.com/<strong>2018</strong>/06/20/instagram-1-billion-users/<br />
2. Keracher M. #StatusOfMind. London UK: Royal Society<br />
for Public Health; 2017. pp. 5, 10, 24-26. Available from: https://<br />
www.rsph.org.uk/uploads/assets/uploaded/62be270a-a55f-4719-<br />
ad668c2ec7a74c2a.pdf<br />
3. Newspoll Market and Social Resources. Like, post, share:<br />
Young Australians’ experience of social media. Canberra ACT:<br />
Australian Communications and Media Authority; 2013. p. 8.<br />
Available from: https://www.acma.gov.au/-/media/mediacomms/<br />
Report/pdf/Like-post-share-Young-Australians-experience-ofsocial-media-Quantitative-research-report.pdf?la=en<br />
4. Australian Bureau of Statistics. Older persons internet use –<br />
20<strong>12</strong> – 2013 Multipurpose Household survey [Internet]. Canberra<br />
ACT: Australian Bureau of Statistics; 2014 [updated 2016 February<br />
17; cited 20<strong>12</strong> Nov 20]. Available from: http://www.abs.gov.au/<br />
ausstats/abs@.nsf/Lookup/<br />
5. Sensis. Sensis Social Media Report 2017. Melbourne<br />
VIC: Sensis; 2017. Chapter 1. Available from: https://irp-cdn.<br />
multiscreensite.com/535ef142/files/uploaded/Sensis-Social-<br />
Media-Report-2017.pdf<br />
6. VanSlyke T. Digital natives, digital immigrants: some<br />
thoughts from the Generation Gap. The Technology Source<br />
[Internet]. 2003 May/June [cited <strong>2018</strong> Nov 20]. Available from:<br />
http://technologysource.org/article/digital_natives_digital_<br />
immigrants/social media addiction 5% - 3<br />
7. Hofmann W, Vohs KD, Baumeister RF. What people desire,<br />
feel conflicted about, and try to resist in everyday life. Psychological<br />
Science. 20<strong>12</strong> Jun [cited <strong>2018</strong> Nov 20];23(6):582-8.<br />
8. Jenner F. At least 5% of young people suffer symptoms of<br />
social media addiction [Internet]. Brussels BEL: Horizon: the EU<br />
Research & Innovation Magazine; 2015 [updated 2015 April 29;<br />
cited <strong>2018</strong> Nov 20]. Available from:<br />
9. https://horizon-magazine.eu/article/least-5-youngpeople-suffer-symptoms-social-media-addiction_en.html<br />
10. van den Eijnden RJ, Lemmens JS, Valkenburg PM. The social<br />
media disorder scale. Computers in Human Behavior. 2016 Aug<br />
[cited <strong>2018</strong> Nov 20] 1;61:478-87.<br />
11. Dossey L. FOMO, digital dementia, and our dangerous<br />
experiment. Explore: The Journal of Science and Healing. 2014 Mar<br />
1 [cited <strong>2018</strong> Nov 20];10(2):69-73.<br />
<strong>12</strong>. Lamb B. 2015. Human diversity: Its nature, extent, causes<br />
and effects on people [Internet]. Singapore: World Scientific<br />
Publishing; 2015.<br />
13. Smith K. 41 incredible Instagram statistics [Internet].<br />
Brighton UK: BrandWatch; 2015 [updated <strong>2018</strong> April 25; cited<br />
<strong>2018</strong> Nov 20]. Available from: https://www.brandwatch.com/blog/<br />
instagram-stats/<br />
14. Primack BA, Shensa A, Escobar-Viera CG, Barrett EL, Sidani<br />
JE, Colditz JB, James AE. Use of multiple social media platforms and<br />
symptoms of depression and anxiety: A nationally-representative<br />
study among US young adults. 2017 April 1 [cited <strong>2018</strong> Nov 20];<br />
69:1-9.<br />
15. Lin LY, Sidani JE, Shensa A, Radovic A, Miller E, Colditz JB,<br />
Hoffman BL, Giles LM, Primack BA. Association between social<br />
media use and depression among US young adults. Depression<br />
and anxiety. 2016 Apr [cited <strong>2018</strong> Nov 20];33(4):323-31.<br />
16. Sampasa-Kanyinga H, Lewis RF. Frequent use of social<br />
networking sites is associated with poor psychological functioning<br />
among children and adolescents. Cyberpsychology, Behavior, and<br />
Social Networking. 2015 Jul 1 [cited <strong>2018</strong> Nov 20];18(7):380-5.<br />
17. O’Keeffe GS, Clarke-Pearson K. Clinical report—the impact<br />
of social media on children, adolescents, and families. Pediatrics.<br />
2011 Mar 22 [cited <strong>2018</strong> Nov 20]:peds-2011.<br />
18. Australian Bureau of Statistics. National Survey of Mental<br />
health and Wellbeing: summary of results, 4326.0, 2007 [Internet].<br />
Canberra ACT: Australian Bureau of Statistics; 2007. Available<br />
from http://www.ausstats.abs.gov.au/Ausstats/subscriber.<br />
Correspondence<br />
nina.li@student.unsw.edu.au<br />
45
United Nations Climate Conference<br />
Conference report<br />
Georgia Behrens & Katherine Middleton<br />
Georgia Behrens and Katherine Middleton are second-year medical students<br />
at the University of Notre Dame and the University of Western Australia<br />
respectively. They are the <strong>2018</strong> Project Coordinators for AMSA Code Green,<br />
and the 2019 National Student Rep-Elect for Doctors for the Environment<br />
Australia.<br />
Who are you, and what is AMSA Code<br />
Green?<br />
We are Katherine Middleton and Georgia<br />
Behrens, second-year medical students with a<br />
passion for the environment and health. With<br />
a national team, we run AMSA Code Green,<br />
which is AMSA’s climate change and health<br />
project. We provide a platform for Australian<br />
medical students to respond to our planet’s<br />
health emergency - educating, engaging and<br />
advocating on the health challenges posed by<br />
climate change.<br />
In May <strong>2018</strong>, we joined the International<br />
Federation of Medical Students’ Associations<br />
(IFMSA) delegation to the United Nations (UN)<br />
Climate Conference in Bonn, Germany. We spent<br />
two weeks watching, learning, sightseeing, and<br />
doing a bit of casual international environmental<br />
activism.<br />
What is the UN Climate Conference?<br />
The UN Climate Conference is an international<br />
meeting of diplomats, policy-makers, scientists,<br />
academics and non-governmental organisations,<br />
all working together to confront the challenges<br />
posed by climate change.[1] This meeting occurs<br />
every year in Bonn, Germany, and focuses on<br />
continual implementation of the Paris Agreement.<br />
The Paris Agreement, which came into force in<br />
late 2016, unites countries around the world to<br />
take action on climate change. 178 countries<br />
are currently signed up as parties to the Paris<br />
Agreement, and are thus committed to acting<br />
for climate change mitigation and adaptation.<br />
The Paris Agreement commits nations to actively<br />
prevent increases in global temperatures to well<br />
below 2 o C.<br />
The key aim of this year’s UN Climate<br />
Conference was to develop the operating<br />
manual for the implementation of the Paris<br />
Agreement, also known as the “Paris Agreement<br />
46
Rulebook”. This rulebook will be a guide for all<br />
involved countries as to how they should go<br />
about conducting climate change mitigation and<br />
adaptation activities in the upcoming years.[2]<br />
The rulebook is due to be finalised at the end of<br />
<strong>2018</strong> at the 24th Conference of Parties (COP24) in<br />
Katowice, Poland. The significance of COP24 has<br />
earned its name “Paris 2.0” (COP21 was where the<br />
Paris Agreement was signed).<br />
Why do medical students go?<br />
At every UN Climate Conference, hundreds of<br />
people from around the world<br />
come as “observers” to watch,<br />
learn and contribute to the UN<br />
Climate process, even though<br />
they are not parties to the Paris<br />
Agreement. Youth observers<br />
(‘YOUNGOs’) are a particularly<br />
important group at every<br />
conference, as the UN “recognizes<br />
the key role that youth play in<br />
tackling climate change”.[3]<br />
The IFMSA has been sending<br />
youth observers to UN Climate<br />
Conferences for a number of<br />
years. This is because the IFMSA<br />
believes that climate change is an immense<br />
global health issue, an issue which future medical<br />
doctors should be working hard to address as a<br />
matter of urgency.<br />
The preamble of the Paris Agreement<br />
acknowledges “climate change is a common<br />
concern of humankind” and states that climate<br />
action must respect “obligations on human rights<br />
[including] the right to health”.[4] Over the past<br />
few years, IFMSA delegates have been working<br />
hard at UN Climate Conferences to ensure that<br />
parties to the Paris Agreement remember that<br />
climate change is a significant health issue.<br />
‘... the IFMSA believes<br />
that climate change<br />
is an immense global<br />
health issue, an issue<br />
which future medical<br />
doctors should be<br />
working hard to<br />
address as a matter of<br />
urgency.’<br />
What did we do there?<br />
We did so many wonderful things while<br />
attending the conference. First and foremost,<br />
we had the opportunity to meet amazing people<br />
from around the world, all working incredibly<br />
hard to fight climate change and ensure the<br />
ongoing health of our planet. These included<br />
other globally-minded medical students and<br />
youth environmental activists from a wide variety<br />
of countries. We also had the privilege to interact<br />
with representatives from the World Health<br />
Organisation (WHO), and the Executive Secretary<br />
of the UN’s main climate change<br />
organisation, the United Nations<br />
Framework Convention on Climate<br />
Change (UNFCCC).<br />
We sat in on the international<br />
negotiation sessions between<br />
different countries about the<br />
Paris Rulebook, which was an<br />
incredible experience. Getting to<br />
see how the UN works in reality<br />
is a fascinating (if sometimes<br />
bewildering) experience. Alongside<br />
the negotiations, we were able to<br />
attend a range of presentations and<br />
workshops that were being run at the conference.<br />
This included the WHO’s talk regarding health<br />
impacts of air pollution; a legal team aiding a group<br />
of Swiss grandparents in their action of suing the<br />
government for a lack of action towards climate<br />
change; and many presentations addressing the<br />
need to empower women and youth to lead the<br />
charge on climate activism.<br />
Finally, we got involved in a bit of activism to<br />
help remind all the delegates of the urgent health<br />
issues posed by climate change. In both weeks<br />
of the conference, the IFMSA delegation held a<br />
little “action” in the main lobby where we dressed<br />
up in lab coats, stethoscopes and more. We were<br />
47
extremely appreciative at how well-received we<br />
were, and the never-ending interest of others<br />
regarding climate change and health.<br />
about the following questions with regards to<br />
climate change: Where are we? Where do we<br />
want to go? How do we get there?<br />
What did we learn?<br />
There is a tremendous amount of bureaucracy.<br />
At first, it seemed a bit overwhelming and<br />
sometimes even counterproductive. But as the<br />
week progressed, its purpose became evident.<br />
The complexity of climate action on a global scale<br />
is such that a one-size-fits-all approach to climate<br />
mitigation is not feasible. Discussions within the<br />
conference were at times tense for this reason.<br />
A phrase we heard time and time again was the<br />
need for a “just transition” towards a<br />
more renewable future. It taught us<br />
that at a global level, climate action<br />
needs to be well considered and<br />
carefully planned, which is the key to<br />
the UNFCCC process. Climate action<br />
can seem complex in a developed<br />
country such as Australia, and global<br />
climate action is no different.<br />
However, young people are<br />
playing a key role in shaping climate<br />
action. The voices of YOUNGOs<br />
are surprisingly being listened to,<br />
especially as the youth are increasingly<br />
contributing to UN processes. We<br />
also learnt that Pacific nations, in<br />
particular Fiji, are leading the way in the climate<br />
change conversation. The Fijian COP23 President<br />
called for an international dialogue, whereby<br />
party delegates and stakeholders levelled to<br />
share stories and take stock of collective efforts to<br />
achieve targets of Paris Agreement. A Talanoa is a<br />
traditional word used in Fiji to describe a process<br />
of sharing ideas, skills and experiences through<br />
storytelling.[5] We were fortunate enough to join<br />
with other YOUNGOs in our own Talanoa, where<br />
youth from all around the world shared stories<br />
‘... climate<br />
change cannot be<br />
approached from<br />
only one discipline.<br />
It needs to become<br />
integrated into all<br />
aspects of public<br />
policy.’<br />
From this sharing of stories we came to realise<br />
that globally, we are all in a similar place in terms<br />
of climate change, but it is manifesting differently<br />
across nations. We all think that education, in a<br />
way that people can understand and relate to<br />
their own lives, is of utmost importance moving<br />
forward. However, climate change cannot be<br />
approached from only one discipline. It needs<br />
to become integrated into all aspects of public<br />
policy. These stories from our peers were<br />
inspiring and invigorating. We<br />
learnt about the current state<br />
of affairs around the world, and<br />
became hopeful that if we work<br />
together we can figure out how<br />
to effectively tackle climate<br />
change.<br />
Acknowledgements<br />
None<br />
Photo credits<br />
Georgia Behrens & Katherine<br />
Middleton<br />
Conflicts of interest<br />
None declared<br />
Correspondence<br />
georgia.behrens@amsa.org.au<br />
katherine.middleton@amsa.org.au<br />
References<br />
1. United Nations Framework Convention on Climate<br />
Change (UNFCCC). What are United Nations Climate Change<br />
Conferences? [Internet]. New York City, US: UNFCCC; <strong>2018</strong><br />
[updated n.d.; cited <strong>2018</strong> Oct 5]. Available from: https://unfccc.<br />
int/process/conferences/what-are-united-nations-climatechange-conferences<br />
2. United Nations Framework Convention on Climate<br />
48
Change (UNFCCC). Understanding the UN Climate Change<br />
Regime [Internet]. New York City, US: UNFCCC; <strong>2018</strong> [updated<br />
n.d.; cited <strong>2018</strong> Oct 5]. Available from: https://bigpicture.<br />
unfccc.int/<br />
3. United Nations Framework Convention on Climate<br />
Change (UNFCCC). Partnerships [Internet]. New York City,<br />
US: UNFCCC; <strong>2018</strong> [updated n.d.; cited <strong>2018</strong> Oct 5]. Available<br />
from: https://unfccc.int/topics/education-and-outreach/<br />
workstreams/youth-engagement/partnerships<br />
4. United Nations Framework Convention on Climate<br />
Change (UNFCCC). The Paris Agreement [Internet]. New York<br />
City, US: UNFCCC; <strong>2018</strong> [updated n.d.; cited <strong>2018</strong> Oct 5].<br />
Available from: https://unfccc.int/sites/default/files/english_<br />
paris_agreement.pdf<br />
5. United Nations Framework Convention on Climate<br />
Change (UNFCCC). <strong>2018</strong> Talanoa Dialogue Platform [Internet].<br />
UNFCCC. New York City, US: UNFCCC; <strong>2018</strong> [updated n.d.; cited<br />
<strong>2018</strong> Oct 5]. Available from: https://unfccc.int/topics/<strong>2018</strong>-<br />
talanoa-dialogue-platform.<br />
What you need to know:<br />
• In May, AMSA Code Green Project Coordinators attended<br />
the UN Climate Conference in Bonn, Germany. At the<br />
conference, politicians, NGO representatives and citizens from<br />
around the world met to discuss the implementation of the<br />
Paris Agreement, in order to limit global temperature rises to<br />
well below 2.0 degrees celsius.<br />
• The AMSA Code Green Project Coordinators joined a<br />
delegation of medical stduents advocating for the consideration<br />
of the health impacts of climate change in the Paris Agreement<br />
implementation process.<br />
49
There is No Me Without You<br />
Book review<br />
Juliana Wu<br />
Juliana Wu is a first year medical student at the University of<br />
Melbourne.<br />
There is No Me Without You: One Woman’s<br />
Odyssey to Rescue Africa’s Children.<br />
Melissa Fay Greene’s traveller’s account,<br />
There is No Me Without You, is the story of<br />
Haregewoin Tefarra, a middle-class Ethiopian<br />
widow, who opens up her dwelling as a refuge<br />
for hundreds of children orphaned by acquired<br />
immunodeficiency syndrome (AIDS). The book<br />
presents a stark image of the AIDS crisis in Africa<br />
and its decimating effects on Ethiopia. Against<br />
prevailing stigmas and the blind eye taken by<br />
the international community in its denial of the<br />
humanitarian crisis taking place in Ethiopia,<br />
Haregewoin’s selfless acts shine as a joyous<br />
counterpoint to the bleak reality that continues<br />
to consume large parts of Africa.<br />
Greene’s book is an overdue reminder that<br />
our humanity is the key ingredient in combating<br />
the global fight against AIDS. By illustrating each<br />
child’s haunting story of becoming an orphan,<br />
Greene not only addresses, but confronts,<br />
many paradigms in popular culture. Specifically,<br />
she tackles the widespread suggestion that<br />
promiscuity and hypersexual behaviours are to<br />
blame for the continuation of the AIDS epidemic<br />
in Africa. Her stories render this stigma as unfair<br />
and over-simplified. Instead, a prevailing feeling<br />
of defeat and a distinct lack of alternatives<br />
dominate the stories. One woman contracted<br />
AIDS from a man who had “lied in saying he<br />
would marry her” and fled when he found out<br />
she had the disease.[1] The inexorable shame<br />
and guilt she felt in bringing a baby into this<br />
world without the capacity to support it became<br />
a driving factor behind the mother’s decision<br />
to abandon the child. Her story is a testament<br />
to the helplessness of those under the pressure<br />
of extreme marginalisation. Others in the book<br />
would come to feel the force of unimaginable<br />
accusations and violence after being infected<br />
with human immunodeficiency virus (HIV) by<br />
a single unsterile injection.[1] Thus, the book<br />
exemplifies the dangerous stigma towards<br />
those who contract the “unspeakable” disease,<br />
and although Greene does not explicitly state it,<br />
she certainly alludes to the systemic failure of both<br />
domestic and international governments in allowing<br />
the crisis to escalate and social stigmas to linger.[1]<br />
Although the social, economic and political<br />
insufficiencies of Ethiopian governance are all too<br />
obvious throughout the book – for instance, Greene<br />
mentions that Ethiopia ranked 170th out of 177<br />
nations for its Human Development Index, and 134th<br />
out of 140 nations for its gender inequality-related<br />
development index – one cannot help but sympathise<br />
with the Ethiopian context.[1] The so-called “free-fall”<br />
of health and happiness in Ethiopia is the result of a<br />
multiplicity of domestic issues, including border wars,<br />
50
a history of weak and irresponsive leadership, and<br />
the lasting effects of colonisation and international<br />
oppression. Moreover, the onset of social collapse<br />
has been hastened by international politics and<br />
imposition. First world trade policies, which forced<br />
African countries to assimilate and compete against<br />
the global market in the name of “economic<br />
modernisation”, with a climate that heavily favoured<br />
Western economies, meant that African countries<br />
were becoming increasingly dependent on foreign<br />
food imports whilst their exports rapidly declined in<br />
value. This, in combination with stringent conditions<br />
associated with developmental loans, eventually<br />
required the slashing of vital public sectors such<br />
as health and education as a means of reducing<br />
government expenditure. Despite this, Greene is<br />
careful not to lay the blame purely on international<br />
delinquency in the domains of political, economic<br />
and social governance. She notes that instances of<br />
governmental failure and corruption in Ethiopia’s<br />
history, including concealment of famine, vastly<br />
excessive military expenditure, and ongoing ethnic<br />
tensions, have all contributed to the rampant state of<br />
HIV/AIDS in Ethiopia.<br />
Yet one could argue that by the time the AIDS<br />
epidemic had hit Ethiopia, the sustained stagnation<br />
of the Ethiopian economy and international<br />
impositions had rendered it almost impossible<br />
for Ethiopia to properly handle the crisis without<br />
international intervention. It follows then, that the<br />
AIDS epidemic is a blatant example of deliberate<br />
ignorance by the Western world. In a country where<br />
two-thirds of school-age children are not in school,<br />
only 41% of adults can read, and 81% of people live<br />
on less than two dollars a day, the country is simply<br />
not equipped with the resources and administration<br />
it needs to win the war against AIDS.[1] Indeed, it<br />
could be argued that the delay in the provision of<br />
antiretroviral treatments is an issue of international<br />
irresponsibility rather than domestic governance.<br />
For instance, Greene mentions that the Unites States<br />
government stood against mass-producing cheap<br />
drugs as a method of protecting the profits of<br />
American multinational pharmaceutical corporations.<br />
This was done at the expense of some millions of<br />
people in Africa dying of AIDS under the illusory<br />
pretence of “public health realism”.[1] Without lifesaving<br />
antiretroviral treatment, the helplessness<br />
and impossibility of resurrecting the AIDS situation<br />
is made manifest by the character, Dr Rick Hodes.<br />
Although he was an American doctor, he knew that<br />
“without the antiretroviral medication, he couldn’t<br />
save a single life”.[1] Arguably then, Ethiopians,<br />
especially those who contracted HIV, fell victim<br />
to misallocated resources and the neglect of the<br />
international community.<br />
However, this argument is limited in many ways, a<br />
point that Greene is quick to emphasise. In the age<br />
of the AIDS pandemic, there were those both within<br />
Ethiopia, such as Haregewoin, and those outside<br />
the borders of the country, such as Dr. Rick Hodes,<br />
who worked tirelessly to suppress the epidemic<br />
that had infiltrated the country. More specifically,<br />
Greene emphasises families from foreign countries<br />
who provided lifelines to orphaned children through<br />
adoption. In direct opposition to the widespread<br />
negligence of the West in failing to provide lifesaving<br />
medication to Ethiopia, the adoption of<br />
unwanted, psychologically traumatised, and at times<br />
deathly sick orphans by otherwise well-off families is<br />
a testament to the fortitude and love of the human<br />
spirit. Thus, just as Ethiopia may be considered<br />
a victim of international immobility, it was also<br />
arguably the recipient of an altruistic salvation by the<br />
international community.<br />
In conclusion, the book discusses the African AIDS<br />
crisis in a powerful yet sensitive manner. Greene<br />
does well in addressing the multiple facets of the<br />
AIDS pandemic: the relentless social stigmas, lack<br />
of treatment options, international neglect and the<br />
burgeoning number of families destroyed by the<br />
pandemic. Although the book itself brims with grief,<br />
it also stands as a testament to what a single human<br />
being or family can do for others “in a place with no<br />
people”.<br />
‘Against prevailing stigmas<br />
and the blind eye taken by the<br />
international community in<br />
its denial of the humanitarian<br />
crisis taking place in Ethiopia,<br />
Haregewoin’s selfless acts shine<br />
as a joyous counterpoint to the<br />
bleak reality that continues to<br />
consume large parts of Africa.’<br />
Acknowledgements<br />
None<br />
Photo credits<br />
There is No Me Without You: One Woman’s<br />
Odyssey to Rescue Africa’s Children Melissa Fay<br />
Greene]. Bloomsbury USA. 2016 [cited 5 October<br />
<strong>2018</strong>]. Available from: https://www.<br />
bloomsbury.com/uk/there-is-no-me-withoutyou-97815969<strong>12</strong>939/<br />
Conflicts of interest<br />
None declared<br />
Correspondence<br />
julianaw@student.unimelb.edu.au<br />
References<br />
1. Greene, M. (2006). There is No Me Without You [Book]. New<br />
York: Bloomsbury [cited <strong>2018</strong> Sept 17].<br />
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